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76A642D APPLICATION FOR PERMIT
76A64
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION FC'R
DING zws �////�S
JOHN A. LAMBIE, County Engineer RESS (/N/�/
WILLIAM A. JENSEN, Sup't of Building
ALITY
REST
FOR APPLICANT TO FILL IN 55 5T. '
LEGAL hA/ /I�.L/ /- -s
DESCRIPTION LOT NO. �, 6 -� OWNER V, (/{/'G'L+✓�
MAIL
BLOCK- TRACT, / ADDRESS
/��f $O L / Q �•-a .. /}/� /rye (/,.
SIZE OF LOT , � NOW OONB LOT S CITY /Ob 40rJ TEL. NO. `y'� (D•� a/�T�
USE OF ,+ a'r^�, r DISTR'C
NO. GROUP MAP PROCESSED BY
BUILDINGS \ &-
nn JBK PG
CONTRACTOR CO . .l9�.�� k S ADDRESS (� Q CONNECTION DSTATDEPTH
TEL. NO. V.
/� STATE M ANHOLE REFERENCE U ER
REGISTRATION NO. G�/� ❑ COUNTY �~ LOWS T
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTIO LENGTH FROM
HOUSE SEWER CONNECTING TO 1 Y. CURB P.L. M.L.TO P.L.
PUBLIC SEWER @ S5.00 t� C�
SEPTIC TANK,SEEPAGE PIT OR P C NO. O
CO:IMP. NO. JOB NO.
PITS AND/OR DRAINFIELD @ .$10.00 V
HOUSE SEWER CONNECTING TO TRUNK P MIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM @ S3.00 ^
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVER EASEMENT RECORD.IN5TR.NO, DATE I�
WORK TO HOUSE SEWER @ S3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD ll.l
EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $5.00
ALTER.REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING N
SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHMENT - Z
y PERMIT NO,
INDUSTRIAL
WASTE APPROVAL
CHARGES
O RAS PERMIT s 2 00
AUTHORIZATION TOTAL FEE Q CONNECTION CHARGE FEE
'1HAVE 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 INSPECTO'R'S SIGNATURE
SIGNED THIS DAY OF
OWNER OR NEW HOUSE SEWER dv:i-"^ / .�'S.l+;-.�' _�.":•'
OWNERS AGENT CONNECT ADDITIONAL y
BUILDING OR WORK
ADDRESS SEPTIC TANK.SEEP,PIT(S)
I HEREBY .ACKNOWLEDGE THAT I HAVE READ THIS 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 ESCRIBED RESIDENTIAL PROPERTY. ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMITTEE SEEP,PIT(S) ❑ CESSPOOLS ❑ /q A /
VALIDATION ROBERT A. WOOD
CK. M.O. CASH SUPERVISING MECHANICAL ENGINEER
-
Hoc, .� 2 4.�,. MAY 1,2 1 e D 7.-00-
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