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DIVISION OF BUILDING ARID SAFETY SEWER—SEWAGE D O S POSH L � f
Deportment of County Engineer
County of Los Angeles e
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS" ry )tiLL L
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- CASSATT D. GRIFFIN, SUPT of BUILDING LOCALITY
FOR APPLICANT TO FILL IN ceoss sT.
LEGAL
DESCRIPTION . L T NO. OWNER ���►� / P�����:�� i ,.,�
' yI MAIL p
BLOCK TRACT ✓.Sfyr/VLf��-z.� Gr-f�-i.r.. ADDRESS
C' —NO. OF BLDGS. CITY_. - TEL. NO.
SIZE OF LOT •{. NOW ON LOT _ c USE OF DISTRICT NO. GROUP 'MAP
BUILDINGS L 'dG' r4 PG �}
CONTRACTOR '? L//
ADDRESS �.t. CONNECTION DATA
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�' � �� ' vr ti,,.- � l
STATION GI DEPTH
CITY.�7.�.,.Z �„gTEL. N0. i
MANHOLE REFERENCE -/ "a- 'R
❑ STATE
� REGISTRATION NO. L ❑ COUNTY
-No. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO r7 TYPE OF CONN CTION LENGTH FROM
PUBLIC SEWER @ $3.
SEPTIC
�� - Y'.r .L. M.L.'TO P.L. 3, -
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ .$3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD P. C. NO. 1EXTN..CESSPOOL,DRYWELL,MANHOLE Q $2.00 CO. IMP. NO. ° JOB N0.
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM Q $1.00 "` TRUNK PERMIT NO. ROAD PERMIT NO.
CONNECT ADDITIONAL BLDG.OR STATE ENCROACHMENT
WORK TO HOUSE SEWER @ $1.00 PERMIT NO.
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM Q $1.00 WASTE APPROVAL
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CHARGES
. CONNECTION CHARGE FEE -
OWNER'S PERMIT 1 00
REIMBURSEMENT FEE"
AUTHORIZATION TOTAL FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN PIAMED CON- APPROVALS DATE INSPECTOR'S SIGNATURE
TRACTOR TO CONNECT THE ABOVE" DESCRIBED EXISTING DWELLING AA�
TO THE PUBLIC�SEWER..,, / -, NEW HOUSE SEWER %'7
SIGNED THIS DAY OF •19 CONNECT ADDITIONAL Y
OWNER OR J� = BUILDING OR WORK -
OWNERS AGENT ^O�
i SEPTIC TANK,SEEP,PIT(S)
ADDRESS AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT'] HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
( PLUMBING AND SEWERS. - SEWAGE DISPOSAL SYSTEM
' I HEREBY CERTIFY THAT 1 AM. PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ,DISCONISCON N HOUSE SEW D
CALIFORNIA OR THAT 1 AM THE 6LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENT. L PROPERTY- -BACKFILL SEPTIC TANKS❑
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SIGNATURE d /% SEEP.PIT(S) ❑ CESSPOOLS Z-
OF PERMITTEEa—
Z-1-11
JOHN A. LAMBIE". COUNTY ENGINEER VALIDATION ROBERT A.WOOD, CHIEF PLBG. INSPECTOR
CK. M.0. ASH
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