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76A642D APPLICATION FOR PERMIT
6A642
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING �-y r � �f�11 M
JOHN A. LAMBIE. COUNTY ENGINEER ADDRESS J J' / V /,
COLEMAN W JENKINS, SUP T OF BUILDING 4
LOCALITY T C j �
NEAREST
FOR APPLICANT TO FILL IN CROSS ST
LEGAL P�
DESCRIPTION LOT NO J OWNER f �v
--��• MAIL a
BLOCK TRACT S � ADDRESS
NO OF BLDGS
SIZE OF LOT NOW ON LOT CITY J L4 TEL NO 2 oa 9
USE OF
BUILDINGS DISTRICT NO GROUP MAP PROCESSED BY
BK
PG
CONTRACTORT4 V B 1,o
ADDRESS - t C7 /may P fQ�I'� CONNECTION DATA
CITY N Q� (}y� TEL NO (V 7 S ✓ STATION �I A63"s ^DEPTH
STATE 9 x /)
CLASS �/LIC e( MANHOLE RE F/E RAE NCEV 7//" J ,.� LOWER
LICENSE"NO ! Y v
NO DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
/ HOUSE SEWER CONNECTING TO Y C5 URB P L M L TO P L d
PUBLIC SEWER @ $ 00 4'O O
SEPTIC JOB NO
C NO TANK SEEPAGE PIT OR
PITS AND/OR DRAINFIELD $1000
CO IMP NO ()
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO
PRIVATE DISPOSAL SYSTEM @ $300 O
CONNECT ADDITIONAL BLDG OR AFFIDAVIT I WAW eAS NT RECORD INSTR NO DATE
WORK TO HOUSE SEWER @ $300 W
OVERFLOW SEEPAGE PIT DRAINFIELD d
EXTN CESSPOOL DRYWELL MANHOLE @ $5 00 y
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING Z
SEWER OR DISPOSAL SYSTEM @ $300 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT E 2 00
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE �00
IHAVE 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 DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT_ CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
SEPTIC TANK SEEP PIT(S)
I HEREBY ACKNOWLEDGE THAT 1 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
1.]ILPER
IN THE ABOVE DESCRIB RESIDENTIAL PROPERTY ABANDON HOUSE SEWER
URE BACKFILL SEPTIC TANKS ❑
MITTEE SEEP PIT IS) ❑ CESSPOOLS ❑
VALIDATI JACK R. ALLEN
/�
�,./,� SUPERVISING MECHANICAL ENGINEER
CK M O CASH
LA
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