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76AG42060 APPLICATION FOR PERMIT
76AEA
COUNTY OF LOS ANGELES SEWER--SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDIMG
ADDRESS
IO1iPY A. LAMBIE. County En 14-
WILLIAM A. pENSEN, Supt of BuiiBing LOCALITY
NEAREST
FOR APPLICANT TO FILL IN
CROSS ST.
LEGAL
' TS
DESCRIPTION LOT NO. OWNER �;
MAIL
s;� o
BLOCK j+ TRACY i t t a ADDRESS °° !
NO.OF BLDGS. « I-3 Giq- r5 r f G,b3
SIZE OF LOT w �u NOW ON LOT CITY t!_ L L'r TEL NO. 5
USE OF
BUILDINGS 77^. 4 1 �' DISTRICT NO. GROUP BK MAP PG PRQCEWD BY .r
CONTRACTOR
ADDRESS , :; _ n*y CONNECTION DATA
CITYC g EL.N0. C ;? STATION DEPTH
REGISTRATION N0. E~ ? ,_ STATE MANHOLE REFERENCE UPPER
,;J. .,; , 1 sL` COUNTY LOWER:
Na I D5SGRIPTION OF WORK FEE --
HOUSE SEWER CONNECTING TO
_ U:BLIC SEWER @ $9.00 {TYPE OF CONNECTION - LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR Y. CURB P.L. M.L,TO P.L.
PITS A.ND,'OR_DR_AINFIELD @ S3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN:, CFSSPOOL. DRYWPI-L @ $2.00
HOUSE SEWER CONNECTING TO P.C.NO. -
PR(VATE DISPOSAL SYSTEM Cb, $1.00 Co. CMP, N0, JOB NO.
CONNECT ADDITIONAL BLDG.OR
ORK TO HOUSE SEWER $1.00 TRUNK PERMIT NO, ROAD PERMIT N0. O
W @ v
AZREPA'R OR ABANDON HOUSE STATE ENCROACHMENT
SEWER OR CISPOSAL SYSTEM @ $1.00 .PERMIT N0. _ Q
INDUSTRIAL
WASTE APPROVAL 14
CHARGES eall
OWNER'S PERMIT $ 2�00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE Ism REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON.
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS I DATEINSPECTOR'SSIGN ATURE
TO THE PUBLIC SEWER. -
SIGNED THIS DAY OF 19- NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADDRESS - SEPTIC TANK,SEEP.PITS)
AND/OR DRklNFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWF.LL []
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 I AM THE LEGAL O�NER OF THE ABOVE
DESCRIBED RES(DEN "AL PROPERTY., BACKFILL SEPTIC TANKS ❑
SIGNATURE A .7 .�,. �y' r,� SEEP.PITS) ❑ CESSPOOLS [I
QF P RM'ITTEE
Ela VALIDATION ROBERT A. WOOD
Gx,; M.o. CASH SUPERVISING MECHANICAL ENGINEER
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