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76A642D APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION F�NEAREST
JOHN A. LAMBIE, County Engineer
WILLIAM A, JENSEN, Sup't of Building --- ��,
`�^ j '
FOR APPLICANT TO FILL IN T
DESCRIPTION LOT NO OWNER _
BLOCK TRACT ADDRESS
NO^OF SLOGS. f
SIZE OF LOT NOW ON LOT CITY -' r?- .- ,..-TEL. NO.
USE OF
BUILDINGS ' DISTRICT NO. GROUP MAP PROCESSED BY
- f _ BK P6 -
CONTRACTOR ..,y,...• ``�j!"—C.� X C�W(.11� _.� `,
ADDRE S CONNECTION DATA .
STATION DEPTH
CITY -&#- 1.c,j TEL, NO, 81TA UPPER
.�,..,,.,1�._ •;°y ___-._
REGISTRATION NO_<+.N#- -/ ��aCOUNTY MANHOLE REFERENCE LOWER
No, DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TOY. CURB F,L. M.L.TO P.L.
PUBLIC SEWER a $8.00
SEPTIC TANK,SEEPAGE PIT OR P.C.NO,
PITS AND/OR DRAtNF;ELD 510.00 CO.IMP.NO. JOB NO. 2
U8E SEWER CONNECTI NO TO TRUNK PERMIT NO. ROAD PERMIT NO, O
PRIVATE DISPOSAL SYSTEM $3.00
CONNECT ADDITIONAL BLDG.OR "- �i -\ AFFIDAVt7 WAVVCM RAIIIIW[N? RECORD.INSTR,NO. DATE d'
WORK TO HOUSE SEWER _ ®_ $3.00 j O
OVERFLOW SEEPAGE PIT,DRAINFIELD 1--
EXTN.,CESSPOOL,DRYWELL;MANHOLE $5.00 U
TER,REPAIR O. ABANDON HOUSE HWY.OR B7,WIDENING C
AL
SEWER OR DISPOSAL SYSTEM $3.00 87A7E ENCROACHMENT 1
PERMIT NO.
INDUSTRIAL -
WASTE i.PPROVAL ~{
_ r�
CHARGES r
OWNER'S PERMIT S 1 2� oo --
AUTHORIZATION TOTAL FEE j `' () CONNECTION CHARGE FEE —
'1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING —
TO THE PUBLIC SEWER, APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19_ -
OWNER OR NEW HOUSE.SEWER
OWNERS AGENT CONNECT ADDITIONAL
ADDRESS.___
BUILDING OR WORK
I
EPTIC TANK,SEEP,PITS)
I
HEREBY ACKNOWLEDGE THAT 1 HAVE READ^THIS APPLICATIONAND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY -
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS-� ESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY ftHAV 1 AM PROPERLY REGISTERED AND/ORLTER,REPAIR,SEWER OR
LICENSED AS REQUIRf-.D 91Y LOS ANGLES COUNTY AND STATE OFEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT:i A' THE LEGAL OW�R OF, AND INTEND TOSCONNECT PLUG AND
RESIDE IN, THE SCRIBED RE516'E Y L PRO ERTY.
,,,��JJJJJJ�� @ANDON HOUSE SEWER
SIGNATURE , ��� rCKFILL SEPTIC TANKSOF PERMITT � f - ,L.�. EP,PIT(S) ❑ CESSPOOLS ❑
VALIDATION ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
CK. -' M.O. CASH
I.3 iLrG �i U is Ji' '1 6 0 0—
�E$08 10-63
6A642D APPLICATION FOR PERMIT'
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER SEWER-SEWAGE DISPOSAL
BUILDING AND SAFETY DIVISION
JOHN A. LAMBIE, County Engineer ADDRESS
WILLIAM A. JENSEN, Supt of Building
LOCAL'T Y
FOR APPLICANT TO FILL IN CROSS ST.
EG A
MAIL
TRACT ADDRESS
NO.
BLOGS
SIZE 05 LOT N N LOT
USE OF Dlsrpw�T NO, G MAP PROCFSSEO BY
I CCS
BUILDINGS SK
CONTRA CTOR/
x
ADDRESS CONNECTION DATA
STATION DEPTH
CITY TEL.
"tl
MANHOLE REFERENCE -OWER
17c
LEN61H FRO.,
REGISTRATION COUNTY
'TYPE OF CONNECTION
5GRIPTION OF WORK FEE
,f
Y.
0
j HOUSE URB P.L. T I-L,
PUBLIC SEWER @ $5.00
P.C.NO.
SEPTICl--ANK�-SEEPAGE.PITCO. IMP NO. JOB NO. 0
i PITS AND/OR DRAINFIEL.D $I0,00
U
----fHOJSFS-6NER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NZ)
PRIVATE DISPOSAL SYSTEM @ S3,00
S-
-JN 'FR.110.
CONN E C'T AomflopWc B'-bd AFF 1 OAV 17 ��mVER thSCMENT DATE ods
WORK TO HOUSE SEWER @ $3.00 Ik–
OVERFC&WSEEP-A—GFPiT,6"INF!ELD 7
1 EXTN..CFSSFOOL,E)RYVdELL,MAN14OLE@ $5,00
HWY.OR ST.WIDENING
ALTER,REPA,IR OR ABANDON HOUSE
SE
_WER Op. L SYSTEM $3.00-
STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
-PER
CHARGES
OViNE.R S MIT S: 2� 00 CONNECTION.1...r FEE:
AUTHORIZATION[T--0--TA--L-F-EE------
I HAVE A' THIS DATE A CONTRACT WITH TIqr HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO T14E IJB c sEw"R. VALS DATE,: I INSPECTOR S SIGNATURE
SIGNED THIS DAY OF---19--..
OWNER OR NEW 1-40USE SEWER_
OWNERS AGENT------
NNECT ADD!T;ONAL
BUILDING OR WORK
SEPTIC TANK,BEEP,P;T(S)
I HER>BY ACKNOWLEDGE THAT I HAVE READ THIS APPLICA11ON ANID/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITHALL COUNTY ORWNANCES AND STATE LAWS REGULATING
PLUMBING AND _FIVERS. CESSPOOL [j ORYWELL
HE!
'.NH
L Rruy CERTIFY THAT I AM FFfPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
N
Lll--ESED AS REQUIRED BY 1_05 COUNTY ANO STATE OF SEWAGE DISPOSAL SYSTEM
C7-
C AL!'FOR'NIATOR T�> "M A 7-Nf-,Ft?;Q -TSC)NNECT PLUG AND
E 'E N D� '11E L 4 L Qlr�,,'A"N/ NT.ENO TO
V ';��Y
RESIDE 0 v E ukg x
C6�D )IRT ABANDON HOUSE SEW,.R II
SIGNATURE BACKFILL SEP 7•C TANKS
SEEP,PIT(s) f, cv-00-8 DS
VALIDATION ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
CK, M.O. CASH i
D
U,