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6&E-663,11.55 APPLICATION FOR PERMIT - 1
5&E-6
DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Depaxtment of County Engineer
County of Los Angeles BUILDING
JOHN A. LAMBIE,.COUNTY ENGINEER ADDRESS
® CASSATT D. GRIFFIN, SUPT OF BUILDING / -
LOCALITY
FOR APPLICANT TO FILL IN CROS srLEGAL .
DESCRIPTION LOT NO. � � 011 P `J OWNER
y �/l MAIL
BLOCK TRACT � ADDRESS
NO. OF BLDGS. CITY NO.
SIZE OF LOT NOW ON LOT
USE OF
BUILDINGS DIST ICT N0. GROUP MAP
BK PG
CONTRACTOR C 909 ADDRESS �-
CONNECTION DATA
CITY TEL: N0. STATION js' ' ' DEPTH
MANHOLE R FERENCE / ER
RR
STATE LOWER -
REGISTRATION N0. '?j! ❑ COUNTY
NO. DESCRIPTION OF*09K FEE
HOUSE SEWER CONNECTING TOTYPE OF CONNECTIO LENGTH FROM f
PUBLIC SEWER @ $3.50 Y. CURB Pr M.L. TO P.L.
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD c@i $3.00
OVERFLOW SEEPAGE PIT, DRAINFIELD P. C. NO.
EXTN.,CESSPOOL,DRYWELL,M AN H OLE t@ $2.00 CO. IMP. NO. / JOB NO.
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM cr $1.00 TRUNK PERMIT NO. ROAD PERMIT N0,
CONNECT ADDITIONAL BLDG.OR STATE ENCROACHMENT
WORK TO HOUSE SEWER i7a $1.00 PERMIT NO.
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM ct7i $1.00 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT A 1 00
REIMBURSEMENT FEE
AUTHORIZATION TOTAL FEE
I HAVE AT THIS DATE A CONTRACT WITH THE' ERE-IN AMED CON-
APPROVALS DATE INSPECT"79IGNRTURE
TRACTOR TO CONNECT T E ABOVE D IBED EXISTING DWELLING
TO'THE PUBLIC SE NEW HOUSE SEWER `
4V ?PA
SIGNED THIS. DAY OF 1 CONNECT ADDITIONAL S
OWNER - OR BUILDING OR WORK
OWNERS AG p
SEPTIC TANK,SEEP/PIT(S)
ADDRES AND/OR DRAINF LD
I HEREB A K OWLEDG T i HAVE R AD THIS APPL CATION CESSP. a -
AND STATE THAT THE ABOV CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY )RDIN NOES AND STATE LAWS- REGULATING ALTER,REPAIR,SEWER ORw
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM `
IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANG ES COUNTY AND STATE OF ABANDON.HOUSE SEWER
C IFORNIA OR AT 1 A /THE L AL OWN OF - B E
DE ELyRESID I P TY BACKFILL SEPTIC TANKS❑ '
S WR i SEEP.PITS) ❑ CESSPOOLS
F ERMITTEE
JOHN A. LAMBIE, COUNTY ENGINEER VALIDATION ROBERT A. WOOD, CHIEF PL13G. INSPECTOR
CK. M.0. RX H' -
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