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76A642D APPL CA4N FOR PE IT
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER SEWER-SEWAGE DISPOSAL
BUILDING AND SAFETY DIVISION FNEAREST
JOHN A. LAMBIE, County Engineer
WILLIAM A. JENSEN, Sup't of Building
FOR APPLICANT TO FILL IN CROSS ST
LEGAL
DESCRIPTION LOT NO OWNER v
t MAIL
BLOCK TRACT ( [' ADDRESS
NO OF BLDGS
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF
BUILDINGS DISTRICT NO. GROUP MAP �.PRpCESSED BY
EIK
P.
CONTRACTOR f � _
f
ADDRES �CJ CONNECTION DATA
CITY TEL NO /��� STATION_;2 DEPTH
®/FTATE ) ! UPPER
REGISTRATION NO ❑ COUNTY MANHOLE REFERENCE `
NO DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TOCURB P.L M L TO P.L. }
PUBLIC SEWER @ $5.00 —� P G.NO. a
SEPTIC TANK,SEEPAGE PIT OR jy,
PITS AND/OR DRAINFIELD @ $10 00 CO.IMP. NO. JOB NO. • O
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO
PRIVATE DISPOSAL SYSTEM @ $300
CONNECT ADDITIONAL BLDG OR AFFIDAVIT WAIVfN e�5[M rNT RECORD IN5TR NO. DATE O
WORK TO HOUSE SEWER @ $3.00 f..
OVERFLOW SEEPAGE PIT,DRAINFIELD W
EXTN,CESSPOOL,DRYWELL.MANHOLE @ $5.00
WIDENING n"
ALTER.REPAIR OR ABANDON HOUSE HWY OR ST. N
SEWER OR DISPOSAL SYSTEM @ $3 00 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
OWNER'S PERMIT $ 2 00 CHARGES
AU'T'HORIZA'T'ION TOTAL FEE GAJ CONNECTION CHARGE FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED'COONN. REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING lY
TO THE PUBLIC SEWER APPROVALS DATE INSp CTO R'S SIGNATURE
SIGNED THIS DAY OF 19_ 'J! �, ��(��r���✓� 7�
OWNER OR NEW HOUSE SEWER
OWNERS AGENT
CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
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 ElPLUMBING AND SEWERS CESSPOOL ❑ DRYWELL
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSEDAS 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
RESIDE IN, THE AB VE DE CRI BED RESIDE IAL PROPERTY ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS
OF PERMITTEE SEEP,PIT(S) [I CESSPOOLS ❑
1 1
VALIDATION ROBERT A. WOOD
CK M O CASH SUPERVISING MECHANICAL ENGINEER
V� 4'5 3 6 Z JAN 16 1 0 D 7,00- v'