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408 8-60 APPLICATION
®p^� ® p��p ® g����y "-66SF 78A642D A9 9 LICATI®D W FOR tl E R MI�COUNTY OF LOS ANGELES SEWERNEWT, os�1L 1.
DEPARTMENT OF COUNTY ENGINEER
LDING
BUILDING AND SAFETY DIVISION 'nnDRE"
JOHN A. LAMBIE, County Engineer t
WILLIAM A. JENSEN, Supt of Building LOCALITY `
NEAREST
' FOR APPLICANT TO FILL IN CROSS ST.
LEGAL +' • - ,��,>
DESCRIPTION LOT NO.40'V47-77 OWNER
BLOCK TRAC MAIL
dne
,�' ADDRESS
NO OF BLDGS. -
SIZE OF LOT NOW ON LOT CITY EL NO.
USE OF DISTRICT?NO GROUP MAP PROCESSE Y
BUILDINGS I BK PG I / _
CONTRA
ADDRESS -ONNECTION- TA ""
d ION O DEPTH /
CITY _EL.NOS/-- - 7-
• � J �� CSTATE
OUNTY L ANHOLE REFERENCE
REGISTRATION NO
NO DESCRIPTION OF WOTrK FEE f(o�. f( t
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3 00 TYPE OF CONNECTION LENGTH FROM -
_ SEPTIC TANK,SEEPAGE PIT OR Y. CURB P.L. M.L.TO P.L.
ITS AND/OR DRAINFIELD @ $3 00
OVERFLOW SEEPAGE PIT,DRAINFIELD
-EXTN CESSPOOL DRYWELL @ $2 00
HOUSE SEWER CONNECTING TO P.C NO. ,
PRIVATE DISPOSAL SYSTEM @ $1 00 - CO IMP. N0.13 IrLJOB NO. N
CONNECT ADDITIONAL BLDG OR
WORK TO HOUSE SEWER @ 31 00 TRUNK PERMIT NO. ROAD PERMIT N0. V
ALTER,REPAIR O R A SYSTEM HOUSE @ $1 OO s STATE ENCROACHMENT - Iq
SEWERPERMIT NO U
INDUSTRIAL
WASTE APPROVAL W
CHARGES
OWNERS PERMIT $ 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE (9 a 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-SSIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS DAY OF t9_ NEW HOUSE SEWER
OWNER OR i / CONNECT ADDITIONAL 0,
OWNERS AGENT�d-"1�r`i BUILDING OR WORK - - - -
ADDRESS SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD _
1 HEREBY ACKNOWLEDGE THAT 1 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 HAT 1 AM PROPERLY REGI TERED AND/OR DISCONNECT PLUG AND
LICENSED AS RE U D BY LOS ANGELES COUNT AND STATE OF ABANDON HOUSE'SEWER -
CALIFORNIA OR T AT 1 AM THE AL OWF THE ABOVE BACKFILL SEPTIC TANKS ❑
DESCRIBED RE AL PROPERTY. SEEP PITS [:].CESSPOOLSSIGNATURE �
OF PERMIT E
®r VALIDATION ROBERT A. WOOD
CK. N.D, CASN SUPERVISING MECHANICAL ENGINEER
�r�1, 5O4 `^t AI181 0 5 "I0tel
r
r 24650 INS
C A642D 0 APPLICATION. FOR PER I`r
76A642D COUNTY OF LOS ANGELESSEWER-SEWAGE
W ®®�q�pew ® p e
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS
JOHN A. LAMBIE. County Engineer e
WILLIAM A. JENSEN, Supt of Building LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL /�� r
I
ESCRIPTION LOT NOW. Z� .� S/,—// OWNER
LOCK TRACT ,, ,r MAIL
oe�SE i IOSCA C_ ADDRESS
NO.OF BLDGS.
IZE OF LOT NOW ON LOT CITY . . TEL. N0.
SE OF DISTRICT N0. GROUP MAP PROCESSE BY
UILDIN ' BK PG
CTOR DDRESS a •1J C DINECTI )N D TA
CITY TEL.N0.
ION DEPTH
STATEANHOLE REFERENC
REGISTRATION NO. p COUNTY LO ER
N0. DESCRIPTION OF WORK FEE IFT
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3.00 TYPE OF CONNECTION LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR Y. CURB P.L. M.L.TO P.L.
PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE-PIT, DRAINFIELD
EXTN..CESSPOOL. DRYWELL @ $2.00
HOUSE SEWER CONNECTING TO P.C.NO.
PRIVATE DISPOSAL SYSTEM @ $1.00 CO.IMP. NO. JOB NO.
CONNECT ADDITIONAL BLDG.ORa TRUNK PERMIT NO. ROAD PERMIT N0. 06 U
WORK TO HOUSE SEWER @ S1.00
SEWER OR DISPOSAL SYSTEM HOUSE @ $1 00 STATE ENCROACHMENT kv
M0
'' PERMIT N0.
INDUSTRIAL U
WASTE APPROVAL w
CHARGES
OVINE 'S PERMIT g CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
IHAVE<; CON-
T ACTORATO CIONNECT THE ABOVE DESCRIBED EXIISTDATE A CONTRACT WITH THE IINGAMED DWELLIING ±.. APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS AY OF 19— NEW HOUSE SEWER
OWNER OR ��,J'' CONNECT ADDITIONAL
i OWNERS AGE104 BUILDING OR WORK
T
ADDRESS SEPTIC TANK,SEEP.PIS)
AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL ❑ '
WITH ALL COUNTY ORDI ANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
'- PLUMBING AND SEWE S. SEWAGE DISPOSAL SYSTEM
1 HEREBY CEIQ" VAB
T I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS RYLOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR AMTHE OWNS OF THE ABOVE BACKFILL SEPTIC TANKSDESCRIBED RESIROPERTY.
SIGNATURE � SEEP. PIT(S) ❑ CESSP00 S
OF PERMITTEE
®P VALIDATION ROBERT A. WO D
cK. M.o. cases SUPERVISING MECHANICAL ENGINEER
Lf J 5 G 4 5
1 D5.0
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