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31-57 APPLICATION FOR PERN41T
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT Or COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
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JOHN A. LAMBIE. Count E ADDRESS Ly-n]"--,,,L�e re a
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CASSATT D. GRIFFIN, Supt fnv.iOdzizLg
LOCALITY
NEAREST
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FOR APPLICANT TO IN CROSS ST.
LEGAL
DESCRIPTION LOT NO. OWNER 21,c)s e le n Construct"i-on '�'O'
MAIL
BLOCK TRACT 10 uz- c, d
ADDRESS AL
NO,OF SLOGS.
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SIZE OF LOT NOW ON LOT CITY TEL,L,NO.
USE OF
BUILDINGS e.";' DISTRICT NO. GROUP MAP
BK PG
CONTRACTOR (J c'-n s t uc"t'--i'0
ADDRESS -,
CONNEItTION DATA
T
'illDEPTH _.- -7,--
CITY! EL.NO, STATION
STATE MANHOLE REFERENCE UPPER
REGISTRATIN NO.
0 COUNTY
NO_._ DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER ._ _ --3- TYPE OF CONNECTI LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR
ITS AND/OR DRAINFIELD 0 $3.00 Y. CURB 1. M.L.TO P.L.
z
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN_C ESS PO 0 L,DRYW E L L,MA N H 0 LE @ $2,00
HOUSE SEWER E(;&7NC6TING TO P.C NO
.PRIVATE DISPOSAL.SYSTEM @ $1.00 CO.IMP.NO. JOB NO,
CONNECT ADDITIONAL BLDG.OR
WORK TO HOUSE SEWER @ $1.00 TRUNK PERMIT NO. ROAD PERMIT NO,
ALTER,REPAIR OR ABANDON HOUSE -
SEWER OR DISPOSAL SYSTEM @ $1,00 —STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL CHARGES
OWNER'S PERMIT---$ 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE --- 5 00 REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT wiTH THE HEREIN NAMED CON.
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALSDATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS--DAY OF is__ NEW HOUSE SEWER
OWNER ORCONNECT ADDITIONAL
OWNERS AGENT— Nev! BUILDING OR WORK
ADDRESS,- SEPTIC TANK,SEEP.PIT(S)
AND/4R DRAINFIELD
4OHEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
TATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL El DRYWELL 0
AND
ALL
WITH ALL COUNT" ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS, ALTER,REPAIR,SEWER OR
I H
HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR SEWAGE DISPOSAL SYSTEM
LICENSED AS REQUIRED BY LOS
'ELES COUNTY AND STATE OF DISCONNECT PLUG AND
CALIFORNIAD GAL OWNER
CALIFORNIA OR THAT I AM,-I&E OF THE ABOVE ABANDON HOUSE SEWER
DESCRIBED -RESIDE,1*47AL 1`40PERTP BACKFILL SEPTIC TANKS
�'ol z��"'-" - CESSPOOCS 0
T 'F SEEP. PIT(S) EJ
SIGNATURE v
0 0 P, M I T
F PERMiTTE n't�
ROBERT A. WOOD
,VALIDATION
X.0. CASH SUPERVISINGA
MECHANIC 4L ENGINEER
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