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A642D
76A642 0-63 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING 11
JOHN A. LAMBIE, County Engineer ADDRESS
WILLIAM A. JENSEN, Sup't of Building
LOCALITY t
NEAREST
FOR AP,LICANT TO LIN 1 CROSS 5T.
LEGAL - S�
DESCRIPTION LOT NO. OWNER
IL
BLOCK TRACT � �/' 1 DDR
NO. OF BLOCS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF DISTRICT NO. GROUP MAP PROCESSED BY
BUILDINGS
BK PG
CONTRACTOR gr
ADDRESSCONNECTION ATA
CITY L. NO. STATION DEPTH �-
ATE ^ MANHOLE REFERENCE UPPER
REGISTRATION NO. f COUNTY
No. DESCRIPTION OF WORK FEE TYPE OF A TION LENGTH FROM
HOUSE SEWER CONNECTING TO , Y. CURB P.L. M.L.TO P.L.
i PUBLIC SEWER $5.00 n'
SEPTIC TANK,SEEPAGE PIT OR P.C.NO. O
CO.IMP. NO. ]��/` JOB NO.
PITS AN DOR DRAINFIELD @ $10.00 / V
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. 7�f
PRIVATE DISPOSAL SYSTEM @° S3.00 ^
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVER EASEMENT RECORD, INSTR,NO. DATE
WORK TO HOUSE SEWER @ $3.00 V
OVERFLOW SEEPAGE PIT,DRAINFIELD LLI
EXTN.,CESSPOOL,DRYWELL,MA NH OLE @ $5.00
ALTER.REPAIR OR ABANDON HOUSE
HWY. OR ST.WIDENING H
SEWER OR DISPOSAL SYSTEM Q S3.00 STATE ENCROACHMENT
I PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT S 2 00
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE
'I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. APPROVALS DAT E, INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF —19—
OWNER
9_ {
OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL
h BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PITS)
L.ES
HEREBY ACKNOWLEDGE THATI HAVE READ THIS APPLICATION AND/OR DRAINFIELD
D STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLYH ALL COUNTY ORDINANCES AND STATE LAWS REGULATINGMBING AND SEWERS. CESSPOOL ❑ DRYWELLHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND�OR ALTER,REPAIR,SEWER OR
ENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
IFORNIA OR THAT I AM THE LEGAL O NER OF, AND INTEND TO DISCONNECT PLUG AND
IDE IN, THE ABOVE DESCRIBED RES TIAL PROPERTY. ABANDON HOUSE SEWER
NATURE BACKFILL SEPTIC TANKSF PERMITTEE SEEP,PIT(S) ❑ CESSPOOLS ❑
VALIDATION ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
CK. M.O. CASH
8 5m JUL30 1 0 D 7.00ry