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76A68A8�2D2D APPLICATION, FOR PkRM-IT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER-
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS
JOHN A LAMBIE, County En ear
• WILLIAM A JENSEN, Supt of Building LOCALITY
NEAREST
' FOR APPLICANT TO FILL IN
CROSS ST
LEGAL ��. OWN '
DESCRIPTION LOT N0. �
BLOCK TR MAIL
� ADDRESS ,
NO OF BLDGS. '
SIZE OF LOT NOW ON LOT CITY TEL NO.
USE OF DISTRICT NO. GROUP MAP PROCESS BY
BUILDIN
BK PG ,
CONTRACTOR
ADDRESS C NNECTI N DATA
CITY TEL.NO I - DEPTH
TATE ANHOLE REFERENC
REGISTRATION NO. COUNTY LOWER
NO. DESCRIPTION OF WORK FEE
y/
HOUSE SEWER CONNECTING TO `�
PUBLIC SEWER @ $3 00 TYPE OF CONNECTION LENGTH FROM C _
P TS AND/ORSEPTIC NK,SEEPAGE
DRAINFIELD OR @ $3 00 Y. CURB P.L. M.L.TO P4.L.
OVERFLOW SEEPAGE PIT DRAINFIELD +
EXTN CESSPOOL DRYWELL @ $2 00
HOUSE SEWER CONNECTING TO J C. O.
PRIVATE DISPOSAL SYSTEM @ $1 00 CO IMP. N0. I JOB N0. �.
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO ROAD PERMIT N0. V
WORK TO HOUSE SEWER @ $1 00
ALTER, REPAIR ISPOSAL SYSTEM HOUSE @ $1 00 STATE ENCROACHMENT CA
SEWERPERMIT NO. O
N
INDUSTRIAL U
,WASTE APPROVAL W
CHARGES
OWNER'S PERMIT $ 2 00 CONNECTION CHARGE FEE
AUTHORIZATION I 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 �/ INSPECTO •8 SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS AY 19_ NEW HOUSE SEWER
OWNER OR - CONNECT ADDITIONAL r '"
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 IS4CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRY-WELL ❑ '
WITH ALL COUNTY ORDINAN AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THA I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT AM THE LEG OWNER OF HE ABOVE
DESCRIBED RESIDEN PROPERTY. BACKFILL SEPTIC TANKS ❑
,SIGNATURE / SE P PIT(S) CESSP OLS _
OF PERMITTEE
®P VALIDATION/ 1 ROBERT A. WOOD
CK. 11.0. H l SUPERVISING MECHANICAL ENGINEER
LAC05646K, D 0
24650 INSERTS
CE6086.60 APPLICATION
PERMIT
76Iv42D
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL ,,
DEPARTMENT OF COUNTY ENGINEER-
BUILDING AND SAFETY DMSION BUILDING
ADDRESS' ' r
JOHN A. LAMBIE, County
IAAEnggi�nneer
WILLIAM A. JENSEN, Supt of Building' LOCALITY'`
NEAREST
FOR APPLICANT TO TILL IN
LEGAL / �.� f OWNER
DESCRIPTION A0.
BLOCK TRACT MAIL Q
' / -�L•tJ ADDRESS 6
NO OF BLDGS. '-'�
SIZE OF OT NOW ON LOT CITY . TEL. NO.
USE OF DISTRICT NO. GROUP MAP PROCESSE Yl
BUILDfNGS BK PG
CONTRACT ' �
ADDRESStp CWRECTION DATA
CITY TE N0. S TIO DEPTH
SATE ANHOLEREFERENC '241
REGISTRATION NO 1 COUNTY L E
NO DESCRIPTION WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3 00 'TYPE OF NNECTION 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 OR TRUNK PERMIT NO. ROAD PERMIT N0. U
WORK TO HOUSE SEWER @ $1 00
ALTER REPAIR OR ABANDON HOUSE STATE ENCROACHMENT m
SEWER OR DISPOSAL SYSTEM _ $100 PERMIT NO
INDUSTRIAL
WASTE APPROVAL - 0.
CHARGES'
OWNER'S PERMIT $ mw CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE' d-D REIMBURSEMENT FEE
CON-
TRACTOR TO CIONNECT THE ABOVE DESCRIBED EXIISTDATE A CONTRACT WITH THE IJNGAMED DWELLING APPROVALS - DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.-
SIGNED THIS F 19- NEW HOUSE SEWER '
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT �. je� BUILDING'OR.WORK-
ADDRESS SEPTIC TANK,SEEP PIT(S) '
AND/OR DRAINFIELD
1 HEREBY,'ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION - - -h -
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY, . CESSPOOL ❑ DRYWELL ❑ '_ 4 WITH ALL COUNTY OR
DI NCES 'AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIF HAT 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND '
LICENSED AS, RE_Q D BY LOS ANGELES COUNT AND STATE.OF ABANDON HOUSE SEWER
CALIFORNIA ES T I AM THE kF OW OF THE ABOVE BACKFILL SEPTIC TANKS ❑
DESCRIBED REST L PROPERTY. R/T�d/�/ '
SIGNATURE SEEP PIT(S) ❑ CE-WOOLS I
'OF PERMIT.
®� VALIDATION ROBERT A. WOOD
CK. M.0: CA9H SUPERVISING MECHANICAL, ENGINEER
;� 4�✓ _