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6A642 -G9
6A642 L1 APPLICATION FOR P RMIT:
'
COUNTY OF LOS ANGELES SEINER SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER -
BUILDING AND SAFETY DIVISION BUILDING g
gg ADDRESS # Es
W 0L AM'A.JJENSEN,Supt of wilding
LOCALITYNEAREST
;
FOR APPLICANT TO F77.L IN
CROSS 5T. ) f G 11 C
LEGAL 1.�" �
DESCRIPTION LOT N0. Iy OWNER
BLOCK TRACTMAIL
c r' ADDRESS
.NO.OF BLDGS.
SIZE OF LOT NOW ON LOT I CITY TEL. NO
USE OF
BUILDINGS E,. DISTRICT N0. GROUP MAP PROCESSED BY
CONTRACTOR ;, BK PG
ADDRESS` ° yb :��.-- :z CONNECTION DATA
CITY S- i`- n- L.N0. _: STATION i 1
�� t,- J 7 �/. DEPTH v..
REGISTRATION N0. r t ° STATE MANHOLE REFERENCE � � TIPPER
COUNTY ,to x .
NO. DESCRIPTION OF R FEE
HOUSE SEWER CONNECTING TO k-
PUBLIC SEWER v 5 .00 TYPE OF CONNECTION .; LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR Y. CURB 'P.L."` M.L.TO P.L. T
PITS AND/OR DRAINFIELD dtia S .00
OVERFLOW SEEPAGE PIT.DRAINFIELD }
EXTN,.CESSPOOL.DRYWELL @ $;.D0
HOUSE SEWER CONNECTING TO P.C.N0. t'` O
--P IVATE DISPOSAL SYSTEM $1.00 CO.IMP. NO< JOB NO. 7 y�
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT N0, ROAD PERMIT NO,
WORK TO HOUSE SEWER $ .00
SEWER OR DREPAIR OR ISP4SAL ABANDON
YSTE HOUSE 00 STATE ENCROACHMENT
PERMIT NO. ri
INDUSTRIAL
WASTE APPROVAL ®-
�7,�rL+ CHARGES z
OWNER'S RD'S PERMIT s 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE /.... REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER. ---
SIGNED THIS DAY OF i9— NEW HOUSE SEWER
OWNER OR / r CONNECT ADDITIONAL
OWNERS AGENT '--f '°'z BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINF'IELO
I HEREBY ACKNOWLEDGE THAT I HAVE READ TH1S APPLICATION
ANIS STATE THAT THE ABOVE IS. CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING AL TER,REPAIR,SEWER OR
PLUMBING AND SEWERS. .SEWAGE DISPOSAL SYST.EIJ
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 AN THE LEGAL OWNER OF THE ABOVE BACKFILL SEPTIC TANKS ❑
DESCRIBED RE5IDENItAL`PROPERTY. } '' SEEP.P17(S) ❑ CESSPOOLS
SIGNATURE
OF PERMITTEE .R •,`•-. '-� `-s�"b"i"'._`
fj VALIDATION ROBERT A. WOOD
CK.,�r Y.0. CASH SUPERVISING MECHANICAL ENGINEER