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craoa APPLICATION FOR PERMIT
a-59-ss COUNTY OF LOS ANGELES
SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUMDING AND SAFETY DIVISION FA
U I LD I N G
DDRESSrrOHN A. LAMSIE, County En eerCPIS3ATIDGRIFFIN, Supt of Building OCALITY
FOR APPLICANT TO FILL IN EARESTROSS ST.
LEGAL
DESCRIPTION LOT N OWNER r
BLOCK - TRAC MAIL �� -
ADDRESS
NO OF BLDGS.
SIZE OF LOT NOW ON LOT CITY LJ TEL NO.
BUILDINGS DISTRICT NO. GROUP MAP P ESSED
BUILDI
BK PG
CONTRACTOR J�e +
ADDRESS Zrt YelCONNECTION D TA
CITY TEL.NO. !�S� T TION "6 A0 DEPTH,/0
^ 'p �e`J STATE MANHOLE REFERENCE /
REGISTRATION N0. /J /?_/ ( 7 COUNTY 11 LOWER
No. DESCRIPTION OF WORK FEE G
HOUSE SEWER CONNECTING TO /pL �
PUBLIC SEWER Co) $3 00 ` TYPE OF CONNECTION LENGTH FROM4 "
SEPTIC TANK,SEEPAGE PIT OR Y. CURB L. M.L.TO P.L. ..7
ITS AND/OR DRAINFIELD @ $3 00
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN CESSPOOL DRYWELL Co) $2.00
HOUSE SEWER CONNECTING TO / P.C.N0.
PRIVATE DISPOSAL SYSTEM @ $1 00 CO IMP.-N0. / JOB NO.
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT N0. ROAD PERMIT NO
WORK TO HOUSE SEWER @ $f 00
SEWER OR D DISPOSAL SYSTEM HOUSE @ $1 00 STATE ENCROACHMENT
PERMIT N0.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT $ 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE (}-t7 REIMBURSEMENT FEE
DATE A CONTRACT WITH THE HEREINAMED CN-
TRACTOR TO CIONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE I INSPECTOR'S SIGNATURE,
TO THE PUBLIC SEWER.
SIGNED THIS DAY OF 19_ NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT_�Q,��� BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP PIT(S)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL El DRYWELL El
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT I 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 TjiE LEGAL0 ER THE ABOVE
DESCRIBED RESIDENTIA Y. Y BACKFILL SEPTIC TANKS ❑
SIGNATURE
Q
EP.PIT(S) ElCESSPO LS 11OF PERMITT ® �, 77
40
®P VALIDATION ROBERT A. WOOD
cK. M.o. CASH SUPERVISING MECHANICAL ENGINEER
�' - - LG5, 7 6 5%0 JAN 2g 1 0 A 5.40 �
APPLICATION FOR PERMIT
caEnoe8088-sa COUNTY OF LOS ANGELES
DEPARTMENT OLSAFETY
NTY ENGINEER SEWER-SEWAGE DISPOSAL
BUILDING ANDIVISION BUILDING F
ADDRESS
JOHN A. LANatP En eer
,CASSATT D. GRpt of Building LOCALITY 7
NEAREST
FOR APPLICANT TO FILL IN CROSS ST. t® v
LEGAL OWNER ♦ riY C7 .
DESCRIPTION LOT NO.
MAIL
BLOCK TRACT ADDRESS
NO OF BLDGS. _
SIZE OF LOT NOW ON LOT fMANHOLE
T V/ TEL NO
USE OF
BUILDINGS /I O. GROUP MAP OCESSE BY
I BK PGCONTRACTOR 0z ,� mf rADDRESS h1 �l��/ �' CONNECTION DATA
jam` DEPTH
CITY A VTEL.NO. y .. i' J`, ATREFE ENCE
REGISTRATION NO. ^ 7 COUN / WERNO. DESCRIPTION OF WORK FEEHOUSE SEWER CONNECTING TO !PUBLIC SEWER @ $3 00 OF CONNECTION LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR CURB P. M.L.TO P.L.
ITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELDEXTN CESSPOOL DRYWELL @ $2 00
HOUSE SEWER CONNECTING TO P.C.NO.
PRIVATE DISPOSAL SYSTEM @ $1 00 O. JOB NO
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT N0.
WORK TO HOUSE SEWER @ $1 00
SEWER OR DISPOSAABANDON L SYSTEM HOUSE @ $1 00 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNER'S PERMIT $ ',l CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE V L/ REIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING A PROWI S DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER. e
SIGNED THIS DAY OF 19- NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWBUILDING 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 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
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT 1 AM THE LEGAL OWN F THE ABOVE BACKFILL SEPTIC TS E3DESCRIBED RESIDENTIAL PRO RTANKS TY. v p PITS) ElCANK LS ❑
SIGNATURE t a,
OF PERMITT
CP �, UDATION ROBERT A. WOOD
M.0. CASH SUPERVISING MECHANICAL ENGINEER .
,571',6Z .,JO2g. 1 1 A 25.00 �