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7sAsna76A642D.eo APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION Bu1LDINe,r
ADDRESS r:.
ncer
WI®%RM A.A. MBIENCo itt Enii t3ing r' a ?>
P LOCALITY r-_
NEAREST
FOR APPLICANT TO FILL IN CROSS ST .
LEGAL .f �; •-
DESCRIPTION LOT NO. OWNER
: MAIL a° k a
BLOCK TRA( 7. f ADDRESS 9 / r'
1 NO OF BLDGS.
SIZE OF LOT NOW ON LOT CITY' �^ :?' � TEL. N0.
USE of
BUILDiNGS ;' '- DISTRICTNO. 'ROUP MAP PROCESSED
--- — Y BR PG /
CONTRACTOR: '
s
CONNECTION DATA
CITY , •TEL.NO,t� ;'1 STATION d '% DEPTH
_ f t
STATE MANHOLE REFERENCE UPPER
REGISTRATION NO / '`1 COUNTY /��' f}L.,�-�aa�'" byggK';
NO., DESCRI�'�"OF WORK ^ FEE
HOUSES EWER CONNECTING TO f_"
PUBLIC SEWER Q $3.00 I TYPE OF CONN£CTIOI LENGTH FROM
SEPTIC TANK.SEEPAGE PIT OR Y. CURB P. M.L.TO F.L. f
PIT SANWORDRAIN FIELD @ $3.00
OVERFLOW SEEPAGE PIT. DRAINFIELD
EXT-N..CESSPOOL. DRYWF)L @ $2.00
HOUSE SEWER CONNECTING TO � P.C.N0.
PTUVATE DISPOSAL SYSTEM @ $1.00 CO.IMP. NO, �Z y .TOB NO.
CONNECT ADDITIONAL BLDG.OR
WOR`;TO HOUSE SEWER @ $1.00 TRUNK PERMIT NO. ROAD PERMIT NO. O
AL 7ER.REPAIR OR LS"SD N HOUSE i r' U
EWER Ok DISPOSAL SYSTEM C� Si.00 STATE ENCROACHMENTgo
PERMIT NO. O
INDUSTRIAL
WASTE APPROVAL W
CHARGES
OvmEP.'S PERMIT $ 2� 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE I REIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN. NAMED CON- -
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS I DATE INSPECTOR'S.SIGNATURE
TO THE PUBLIC SEWER. IIT------�I
SIGNED THIS DAy OF 19— NEW HOUSE SEWER I_ !
OWNER OR .:� - - _.. CONNECT ADDITIONAL
OWNERS AGENT - BUILDING OR WORK
ADDRESS_ - — _ SEPTIC TANK,SEEP.PITS)
AEPTIC TADRANK,
SEELD
P,
_
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COM-PLY CESSPOOL ❑ DRYWELL C]
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING —,4L7ER,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 THAT I AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDE AL PROPI;RTY BACKFILL SEPTIC TANKS ❑
SIGNATURE ' i. �:'s. .„ ,tyi_ rSEEP.PITS) ❑ CESSFOOL.S ❑
OF PERMITTEEr
" VALIDATIOI�" ROBERT A. WOOD
CIC. X.0. (GASB SUPERVISING MECHANICAL ENGINEER
'J a 5 SUN I C) D `ll.00)'" `