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APPLICATION FOR PERMIT 1
9&E•8
DIVISION OF BUILDING-AND SAFETY SEWER-SEWAGE DISPOSAL
Deportment of County Engineer
County Of Los Angeles ADDRE SS S
JOHN A LAMBIE, COUNTY ENGINEER ADDRE �( �fJ�yy$pJZJ
® CASSATT D GRIFFIN. SUP T OF BUILDINGLOCALITY
- '
FOR APPLICANT TO FILL IN
NEAREST T
LEGAL �� OWNER
DESCRIPTION LOT NO
41 MAIL
BLOCK T ACT/3 5 ADDRESS
SIZE OF LOT )t NOW ON LOTS CITY alb,- TEL NO G67-
USE OF
BUILDINGS DISTRICT NO GROUP MAP
BK PG
CONTRACTOR lJ[ /f /9
• CONNECTION DATA
ADDRESS
CITYEL:NO. STATION DEPTH
MANHOLE REFERENCE '4 i•- �.y-,5 UPPER
ERR
El STATE V /
REGISTRATION NO ❑ COUNTY _
No DESCRIPTION OF WORK FEE U '
HOUSE SEWER CONNECTING TO TYPE OFC TION LENGTH FROM r8 -
PUBLIC SEWER @ $3 50 3 Y. CURB P L M.L TO'P L �>
SEPTIC TANK,SEEPAGE PIT OR -
PITS AND/OR DRAINFIELD @ $3 00
OVERFLOW SEEPAGE PIT, DRAINFIELD •e. P. C NO
EXTN ,CESSPOOL,DRYWELL,MANHOLE @ $2 00 CO IMP NO JOB NO
'HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM - @ $100 TRUNK PERMIT NO. ROAD PERMIT NO .a1 •��-99.3
CONNECT ADDITIONAL BLDG OR STATE ENCROACHMENT
WORK TO HOUSE SEWER @ $100 PERMIT NO.
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM @ $100 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE OWNER'S PERMIT 8 1 00
AUTHORIZATION I TOTAL FEE O REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- APPROVALS DATE INSPECTOR'S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING ,��� /'#` I/f�t
TO THE PUBLIC SEWER NEW HOUSE SEWER /K3Y L
SIGNED THIS Ra DAY OF 1954 CONNECT ADDITIONAL !
OWNER OR BUILDING OR WORK
OWNERS AGENT SEPTIC TANK,SEEP,PIT(S)
ADDRESSdddd�"� AND/OR DRAINFIELD -
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATI N CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVEAS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
IHEREBY 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 I AM THE LEGAL Q1pCNER OF THE ABOV
DESCRIBED RESIDENTIAL PER - (�/f/ IleBACKFILLSEPTIC TANKS'❑
SIGNATURE SEEP PITCl) CESSPOOLS
OF PERMITTEE
JOHN A. LAMBIE, COUNTY ENGINEER VALIDATION ROBERT A WOOD, CHIEF PLBG INSPECTOR
^CK. O. CASH 2 4 •