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COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL-
-DEPARTMENT OF COUNTY ENGINEER
BUILDING AND,SAFETY DIVISION ADDRESSG
JOHN A. LAMBIE, County En ineer �
WILLIAM A. JENSEN, Supt of Building LOCALITY
NEAREST
FOR APPLICANT TO FILL IN cltoss sr.
LEGAL `L.,
DESCRIPTION LOT NO.� � � � OWNER A a�J �', C// -•
BLOCK - TRACT fMAIL
ADDRESS A:: f < � �I
NO OF BLDGS. '
SIZE OF LOT NOW ON LOT ,CITY EL NO
USE OF DISTRICT NO. GR7p �,
MAP ESSED BYBUILDINGS jtl�
K P6
CONTRACTOR r 7
ADDRESS
o�0�, CONNECTION DATA
CITY TEL/NO ySTATION DEPTH
REGISTRATION NO. f SCO 3��'S' rSTATE COUNTY MANHOLE REF RE CE UPPER
LOWER
NO DESCRIPTION OF WORK FEE
OUSE SEWER CONNECTING TO
UBLIC SEWER @ 00 TYPE Ot CONNECTION LENGTH ROM _
SEPTIC TANK,SEEPAGE PIT OR X. CURB L-j M.L.TO P.L.
PITS AND/OR DRAINFIELD @ 1 00 -
OVERFLOW SEEPAGE PIT, DRAINFIELD -
EXTN CESSPOOL DRYWELL @ 2 00 -
C N0.
HOUSE SEWER CONNECTING TO CO IMP. N0. I 0.
PRIVATE DISPOSAL SYSTEM @ 00 - p+
CONNECT ADDITIONAL BLDG OR �--� TRUNK PERMIT NO. RO ER N0.• U
WORK TO HOUSE SEWER @ S 00"
ALTER, REPAIR OSAL SYSTEM HOUSE @ S 00 STATE ENCROACHMENT
PERMIT NO. O
INDUSU
WAST
ETRIA ROVAL WM
CHARGES
OWNERS PERMIT 3 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- _ _
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S-SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS DAY OF 19 NEW HOUSE SEWER '
OWNER OR CONNECT ADDITIONAL '
OWNERS AGENT BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS-APPLICATION,
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL ❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR,
_
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY. LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER -
CALIFORNIA OR' THAT 1 THE LEGAL OF THE ABOVE
DESCRIBED RESIDENTIA RO ERTY. BACKFILL SEPTIC TANKS ❑ '
SIGNATURE c, SEEP PIT(S) C1CESSPOOLS ❑
OF PERMITTE • -
®rVALIDATION ROBERT A. WOOD
M.0. CASH SUPERVISING MECHANICAL ENGINEER
' _ r
7 9 AFR24 L 0 o• ' 5.00