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76n642D COUNTY OF LOS ANGELES ■ SEWER—SEWAGE DOSPO AL 1
DEPARTMENT OF COUNTY ENGINEER p� q A 4. ,�
BUILDING AND SAFETY DIVISION ADDRENG !S 7�JC� - 07 ,L�r) Wei
JOHN A. LAMBIE, County Engineer !�
WILLIAM A. JENSEN, Supt of Building LOCALITY
NEAREST
FOR APPLICANT TO FILL IN 1 CROSS ST.LEGAL
J/ �
DESCRIPTION LOT NO. �{C�AR @9 &(c7f �Q `1 �'C ✓ CA
/� qq OWNER a o�yq�/ p.:
MAIL
BLOCK TRACT �, 9. g60 �® ADDRESSS 91A 104E Clr jC9,00
SIZE OF LOT ,-�� bz ��� NOW ON LOTS CITY / Ol� TEL. NO. .47. 6 T'
USE OF
BUILDINGS DISTRICT NO. GROUPI BKMAP I PRO ESSED
PG c
CONTRACTOR1 �
ADDRESS l,,04t 6d' / , CONNECTION DATA
CITY ry� TEL.N0. STATION DEPTH
❑ STATE MANHOLE REFERENCE
REGISTRATION NO. ❑ COUNTY i LOW
_ No. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3.00 TYPE OF CONNECTION LENGTH FROM 6
SEPTIC TANK,SEEPAGE PIT OR Y. CURB P.L. M.L.
TO P.L.
PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT, DRAINFIELD
EXTN.. CESSPOOL. DRYWELL @ $2.00
HOUSE SEWER CONNECTING TO P.B O. O�
PRIVATE DISPOSAL SYSTEM @ $1.00 CD"tMY"iV'0 JOB N0. o �,
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT N6. O
WORK TO HOUSE SEWER @ $1.00 U
Atg•E1-RE1jj11-9R-ABANDON HOUSE STATE ENCROACHMENT pq
SEWER D'R-B9?991}L SYSTEM @ $1.00 PERMIT NO. O
INDUSTRIAL F
WASTE AP OVAL
P.
CHARGES rA
OWNERS PERMIT $ 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE :3 C-0 REIMBURSEMENT FEE
IHAVECON-
TRACTORATO CIONNECT THE ABOVE ESCR BED EXIISTDATE A CONTRACT WIH THE IINGAMED DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLICSEWER
SIGNED THISOF 19_ NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING 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 El DRYWELL ❑
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 1 AM THE LEGAL OWNER OF a HE ,A'BOV
DESCRIBED RSIBACKFILL SEPTIC TANKS ❑
DE T A RIO SEEP. PIT(S) ❑ CESSPOOLSSIGNATU
❑
OF PER
OF ALIDATION ROBERT A. WOOD
Ca M.0. CASH SUPERVISING MECHANICAL ENGINEER
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