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78A 642DAPPLICATION FOR PERMIT '
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION ADDRESS 6 5 EMAPtPROCESSED
JOHN A, LAMBIE, County Enggi�nneerWILLIAM A. JENSEN, Sup't of Building LOCALITY
NEAREST / nFOR APPLICANT TO FILL IN CROSS ST. 1-4LEGAL / OWNERDESCRIPTION LOT H0.BLOCK TRACT S MAIL
ADDRESS
NO.OF BLDGS.
SIZE OF LOT NOW ON LOT CITY USE OF
BUILDINGS DISTRICT NO. GROG BY
CONTRACTOR Q lK P6
ADDRESS �' CONNECTION DATA L
CITY ' TEL.NO (t•:r_- 6 `'a( STATION DEPTH
STATE
REGISTRATION N0. 6 L COUNTY MANHOLE REFERENCE /� UPPER
NO. DESCRIPTrON OF WORK /FEE C
I
HOUSE SEWER
CONNECTING TOPUBLIC @ 00
TYPE OF CONNECTIO LENGTH FROM
SEPTIC DgNK,SEEPAGE PIT OR Y. CURB .L M.L.TO P.L.
PITS AND/OR DRAINFIELD @ S .00
OVERFLOW SEEPAGE PIT,DRAINFIELD >_
EXTN. CESSPOOL DRYWELL S .00 CL
HOUSE SEWER CONNECTING TO P.C.NO. Env O
PRIVATE DISPOSAL SYSTEM @ S.00 CO IMP. NO. JOB NO. ✓ V
CONNECT ADDITIONAL BLDG.OR
WORK TO HOUSE SEWER S 00 TRUNK PERMIT N0. ROAD PERMIT N0. d'
ALTER,REPAIR OR ABANDON HOUSE STATE ENCROACHMENT 0
SEWER OR DISPOSAL SYSTEM@ $1.00 PERMIT NO V
W
INDUSTRIAL CL
WASTE APPROVAL N
CHARGES ?
OWNSR-S PERMIT $ 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON.
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGN$ITURE
TO THE PUBLIC SEWER.' V.
SIGNED THIS DAY F 19- NEW HOUSE SEWER A;
OWNER OR �1 v,/ CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT t HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR.SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTE
1 HEREBY CERTIFY THAT 1 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 OWNER OF THE ABOVE
DESCRIBED RESIDENIA T
PROPERTY. BACKFILL SEPTIC TANKS ❑
SIGNATURE SEEP.PIS ❑ CESSPOOLS
OF PERMITTEE
VALIDATION ROBERT A. WOOD
CIL u.o. CASH SUPERVISING MECHANICAL'ENGINEER
; ? 0 3 s "'04 t'WI' 2 1 D
7.0�J Ky