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APPLICATION FOR PERMIT 1
8&E-8
DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Deportment of County Engineer
County of LOS Angeles BUILDING %
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS �/ �GqG .� 2aG
® CASSATT D. GRIFFIN. SUPT OF BUILDING LOCALITY
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL .7 OWNER
DESCRIPTION LOT N0. ,J6
MAIL
BLOCK TRACT /n ADDRESS
{{ NO. OF BLDGS. CITY TEL. N0.
SIZE OF LOT NOW ON LOT
USE OF DISTRICT NO. GROUP MAP
BUILDINGS
BK
IG
CONTRACTOR 16- /
ADDRESS 7 M1�j � - ' CONNECTION DATA
! ,i STATION i DEPTH
CITY '�D l{ TEL. NO.�Q y
MANHOLE REFERENCE � UPPEvv
❑ STATE
REGISTRATION NO. ❑ COUNTY
NO. DESCRIPTION OF WORK FEE
/ HOUSE SEWER CONNECTING TO TYPE i CONNECTIO LENGTH FROM
PUBLIC SEWER @ $3.50 7 O Y. CURB P.L. M.L. TO P.L.
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD Q $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD P. C. N0.
+ EXTN.,CESSPOOL,DRYWELL,MAN HOLE Q $2.00 CO. IMP, NO. / V JOB N0.
IY HOUSE SEWER CONNECTING TO
V PRIVATE DISPOSAL SYSTEM Q $1.00 TRUNK PERMIT NO. ROAD PERMIT N
i CONNECT ADDITIONAL BLDG.OR STATE E OACHMENT
I
WORK TO HOUSE SEWER Q $1.00 PERMIT NO.,
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM Q $1.00 WASTE APPROVAL
ARGE
CONNECTION CHARGE E
OWNER'S PERMIT $ 1 Oo
REIMBURSEMENT FEE
AUTHORIZATION I TOTAL FEE V S c
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- APPROVALS DATE INSPECTOR'S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SE ER. NEW HOUSE SEWER
SIGNED THIS � DAY CIF Z47 "e—h/ 19 11
CONNECT ADDITIONAL
OWNER OR � BUILDING OR WORK
OWNERS AGENT / /Y SEPTIC TANK,SEEP,PIT(S)
ADDRESS AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY —
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAA 1 AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTI L PROP TY, q BACKFILL SEPTIC TANKS❑ + �,
SIGNATURE
��/� SEEP.PIT(S) Ll CESSPOOLSEr' ".�y. ...
OF PERMITTEE
JOHN A. LAMBIE. COUNTY ENGINEER yALIDATION ROBERT A. WOOD,CHIEF PLBG. INSPECTOR
CK/ E1.0. CASH
4AC01 5 0 1- OCT 19 4 4..53 O '�