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D 62 APPLICATION FOR PERMIT
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COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION TAAODRESS
NG
JOHN A. LAMBIE. COUNTY ENGINEER COLEMAN W. JENKINS, SUPT. OF BUILDINGTY P ST pFOR APPLICANT TO FILL IN 5T. �S • Ly,', r'
LEGAL
DESCRIPTION LOT NO. !�ly OWNER �9�p
MAIL 6,`
BLOCK TRACT c5 ADDRESS
O
rd
O. OF BLDGS. u S
SIZE OF LOT NOW ON LOT CITY A 2_ TEL. NO.
USE OF
BUILDINGS .+'- - /i DISTRICT NO. GROUP MAP `F;R'B SED BY
BK PG
CONTRACTOR - P ' '!/ ^•;.
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ADDRESSl'~ CONNECTION DATA543 '
Q-� 4ss.r, �.
0' STATION DEPTH
--CITY TEL. NO. -
STATE LTC- MANHOLE REFERENCE UPPER
LICENSE NO: 20;53 5 GLASS Z (� , LOWER d
N0. .DESCRIP 10 OF ORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. - CURB P.L. M.L.TO P.L. O
PUBLIC SEWER @ S5.00
P.C.NO.
SEPTIC TANK.SEEPAGE PIT ORW
PITS AND/OR DRAINFIELD @ 810.00
CO.IMP.NO. JOB NO. ..J
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM @ 53.00 }
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT I WAIVER EASE,,' RECORD, INSTR.NO. DATE
WORK TO 110U5E SEWER @ $3.00 Q
OVERFLOW SEEPAGE PIT.DRAINFIELD d7
EXTN..CESSPOOL.DRYWELL.MANHOLE @ S5.00 O
ALTER.REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING 6a
ISP AL SYSTEM @ $3.00 °' STATE ENCROACHMENT
PERMIT NO. 61l
INDUSTRIAL '
WASTE APPROVAL
CHARGES
OWNERS PERMIT S 21 00
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE
I.HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS 'n`xDAY OF - wd -19
99�0
OWNER OR 4a .� (r NEW HOUSE SEWER
'OWNERS AGENT_ CONNECT ADDITIONAL
a
ADDR ES % Q: ' BUILDING OR WORK
SEPTIC TANK.SEEP,PITS)
I HEREBY ACKNOWLEDGE THAT I VE READ HIS APPLICATION AND/OR DRAINFIELD
.AND STATE-THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
-
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR.SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN. THE ABOVE DESCRIBED .RESIDENTIAL PROPERTY. ABANDON HOUSE SEWER
SIGNATURE
OF PERMITTEE y BACKFILL SEPTIC TANKS
SEEP.PIT(S) ❑ CESSPOOLS ❑
VALIDATION JACK R. ALLEN
SUPERVISING MECHANICAL ENGINEER
Qd°"`+CK. M.0.a CASH
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