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6A64 10_63 APPLICATION FOR PERMI
76A842D
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION fA
UILDING C�7 Liv e
JOHN A. LAMBIE, County Engineer DDRESS J O
WILLIAM A. JENSEN, Sup't of Bu>ldmg
OCALiTY
EAREST
FOR APPLICANT TO FILL IN ROSS 5
LEGAL
DESCRIPTION LOT H `d Q'- ' �J ! OW b�f
MAIL '
BLOCK TRACQ5 ADOR S K r
NO OF BLDGS - J►
SIZE OF LOT NOW ON LOT CITY TEL NO V
USE OF
BUILDINGS DISTRICT NO GROUP MAP PROCESSED BY
r BK PG
CONTRACT
ADDRV67_ ! - ON DATA
S;jjW 4-
NO CJ ,0��/ STATION DEPTH
STATE MANHOLE REFERENCE UPPER
REGISTRATION NO COUNTY LOWER
NO DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y CURB PL ML TO P L }
PUBLIC SEWER @\$S 00
PC NO d
SEPTIC
PITS AND/OR DRAINFIELD @ 31000 C� IMP NOJOB NO O
V
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO
PRIVATE DISPOSAL SYSTEM @ $300 �
CONNECT ADDITIONAL BLDG OR AFFIDAVIT I WAIVII IAIIMINT RECORD INSTR NOT DATE O
WORK TO HOUSE SEWER @ $3 00 F—
OVERFLOW SEEPAGE PIT,DRAINFIELD W
EXTN,CESSPOOL,DRYWELL MANHOLE @ $B 00 p.
____N_ REIIIIIIIIIIIIIIpmABANDON HWY ORST WIDENING (�
SEWER _ SYSTE $3 00 Z� STATE ENCROACHMENT Z
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT $ z 00CHARGES
/J
AUTHORIZATION TOTAL FEE C)_Z- CONNECTION CHARGE 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 S E APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAYF 1
OWNER OR NEW HOUSE SEWER
OWNERS AGENT � m
CONNECT ADDITIONAL
BUILDING OR WORK
ADDR
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION SEPTIC TANK SEEP,PIT(S)
AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR,SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWN OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN THE ABOV DESCRIBED SI L PROPERTY ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTI TANKS ❑ ❑ �/ �(
OF PERMITTEE SEEP PITS) CESSPOOLS
ALIDATION ROBERT A. WOOD
M O CASH SUPERVISING MECHANICAL ENGINEER
' CK
LJj�o 4 9 1 4 JAN 2 g 1 0D Jc,Q 0_
t
l
r
0-63
76A642D APPLICATION FOR PERMIT
6A642tJ
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPO AL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION FIC.
DING
JOHN A. LAMBIE, County Engineer ESS
WILLIAM A. JENSEN, Supt of Building
LITY y7
EST
FOR APPLICANT TO FILL IN S ST
LEGAL
DESCRIPTION LOT NO 457-/ / ,OWNER
',' _ \' MAIL
BLOCK TRACT (�K ADDRESS
NO OF BLDGS
SIZE OF LOT NOW ON LOT CITY TEL NO
USE OF
BUILDINGS DISTRICT NO GROUP MAP P C S BY
(�[ BK PG
CONTRACTORD iJOI
ADDRESS CONNECTIOfNX-D T
CITY Nt � STATION DEPTH
TEL O /A' ���--///
REGISTRATION NO J ? / Q/p ~ ✓ L/ ❑ COUNTY MANHOLE REFERENCE /Or , U
pp
NO DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGT ROM
HOUSE SEWER CONNECTING TO V V Y CURB P L M L TO P L 061
PUBLIC SEWER @ $5 00
P C NO
SEPTIC TANK,SEEPAGE PIT OR ^ d
PITS AND/OR DR INFIELD $1000 CO IMP NO "21 JOB NO /7 O
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT N0�
PRIVATE DISPOSAL SYSTEM @ E3 00 C
CONNECT ADDITIONAL BLDG OR AFFIDAVIT I WAIVER I IA5[.IHi RECORD INSTR NO DATE O
WORK TO HOUSE SEWER @ $300 V
OVERFLOW SEEPAGE PIT DRAINFIELD
EX TN CESSPOOL,DRYWELL MANHOLE @ $5 00
LW
ALTER REPAIR R ABANDON HOUSE '
SEWER OR DIHWY OR ST WIDENING
OSp
SYSTEM @ $3 00 STATE ENCROACHMENT L
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT t 2 00
CONNECTION CHARGE FEE CHARGES
AUTHORIZATION TOTAL FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NA,4ED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS
TO THE PUBLIC SEWER ATp INSPECT�5 SIGRERE
SIGNED THIS �/jDAY OF 19_
OWNER OR __----_ NEW HOUSE SEWER ,
OWNERS AGENT _-'%�/ 'yL j- CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
SEPTIC TANK SPIT(5)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELEEP,D
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING ,
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
LICENSEDAS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABOVFyD SCRIBED RE DENTIAL PROPERTY ABANDON HOUSE SEWER
SIGNATURE I (// BACKFILL SEPTIC TANKS ❑
OF PERMITTEE SEEP,PIT(S) ❑ CESSPOOLS ❑
ALIDATION ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
CK M O CASH
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