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6AG42D APPLICATION FOR PERMIT '
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION gDDREI55 ( L lr1 =f
JOHN A. LAMBIE, COUNTY ENGINEER —
COLEMAN W. JENKINS. SUPT. OF BUILDING Y `
LO CALI7Y rj Y a
NEAREST '-
FOR APPLICANT TO FILL IN CROSS ST 4L
LEGAL
DESCRIPTION_ LOT No ` •"
—_ . OWNER ., .•f p ly- f �'.l i
MAIL _` ' ..
BLOCK TRACT �� .. ADDRESS
NO. OF BLOGS.
TEL. NO.
USE
SIZE OF LOT NOW ON LOT - CITY _ {`G'"F ')OF �- -- --
BUILDINGS ,/;� •6- ;, DISTRICT NO. GROUP MAP PROCESSED BY
BK PG
CONTRACTOR - �
ADDRESS 7 �} n ( f ^'rF � �.• ' I-' CONNECTION DATA
# t / li,' STATION --- -Z DEPTH
CITY - fi, t 1+ L fF TELf: NO. -
UPPER
STATE ." / j .`> ,".: LIC r"�/g MANHOLE REFERENCE - - •rLOWER
LICENSE NO.„_ `! _ Gr`� CL A$$ M _s N �_f�
NO_ .DESCRIPTION OF WORK FEE _ TypEOF CONN CTION,,.rr.; LENGTH FROM
s• HOUSE SEWER CNNECTING T _ Y. CURB. � P.L. � _ W .TO P.L.
OO lL
PUBLIC SEWER $5.00y�y
9 J i1
f Q✓�fl c=`
SEPTIC TANK,SEEPAGE PIT OR f P.G.NO.
CO.IMP
PITS AND/OR DRAINFIELD $)0.00 ;NO. �I� J Q.'.y. .106 NO. u
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM @ $3.Q0—+I-. TRUNK PERMIT NO.. ROAD PERMIT NO. ,„,
t CONNECT ADDITIONAL BLDG OR I. -AFFIDAVIT vi AiVER EAS[r[NT RECORD,INSTR.NO. DATE p�'gi
WORK TO HOUSE SEWER @ $3.00 I �' I tJ
OVERFLOW SEEPAGE PIT DRAINFIELD � I I 0-
EXTN.C ESS POOL.DRYWELL MANHOLE $5.00 * HWY.OR 5T.WIDENING 91
.-t ALTER.REPAIR OR ABANDON HOUSE - z
SEWER OR DISPOSAL SYSTEM $3,00 STATE ENCROACHMENT
PERMIT NO. -
-------- - _INDUSTRIAL — --^
1 WASTE APPROV AL
T�
OVVNER'S PERMIT _ _ $ 2 Oo _ -- -- - CHARGES
AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEE —
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING — APPROVALS ATE- 11 TOWS THE PUSL IC SEWER. , CTOWS SIGNATURE
SIGNED THIS DAY OF 191. ----_---
OWNER OR NEW HOUSE SEWER _
OWNERS AGENT_.—
CONNECT ADDITIONAL _
BUILDING OR WORK 1
ADDRESS------
SEPTIC
DDRESS __ SEPTIC TANK,SEEP,PIT(S)
1 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 ❑
1 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
CAL.I FORN IA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IFI, THE ABOVE DESCRIBED .RESIDENTIAL PROPERTY. .ABANDON HOUSE SEWER
SIGNATURE --- ----- — —
b;yj BACKFILL SEPTIC TANKS []LS
OF PERMITTEE a--` �'+fy. ✓=r:✓ --_—_—_
SEEP.PIT(S) ❑ CESSPOOLS
VALIDATIQN`- `"`a JACK R, ALLEEN
SUPERVISING MECHANICAL ENGINEER
CK. M.O. l CASH
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