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E•6 14.85 APPLICATION FOR PERMIT 1
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DIVISION OF BUILDING AND SAFETY SEWER--SEWAGE DISPOSAL
Department of County Engineer
County of Los Angeles BUILDING
JOHN A LAMBIE, COUNTY ENGINEER AODRESS
CASSATT D: GRIFFIN, SUPT OF BUILDINLOCALITY
NEAREST
_
FOR APPLICANT TO FF17 IN � CROSS ST. �
-- LEGAL
:DESCRIPTION LOT NO OWNER
BLOCK TRACT ADDRESS -
---- -�- -.... --NO.OF BLDG5. z
SIZE OE LOT NOW ON LOT CITY ::.. TEL. 140.
USE OF ---'�---- --- - -------- DISTRICT NO. GROUP MAP
BUILDINGS
- BK PG
CONTRACTOR—
ADDRESS CONNECTION DATA
s ------'__-.. -
r, STATION - DEPTH
CITY TEL. NO. - ---' _-- --
=— MANHOLE REFERENCE _
STATE _ __ - _ _`^LOWER-
REGISTRATION NO. COUNTY `
N0, DESCRIPTION OF WORK FEE TYPE OF CONNECTION, LENGTH FROM —
�HOUSE SEWER CONNECTING TO - I — -�_ Y. CURB P.
L. M.L.TO A.L.
i PUBLIC SEWER @ $3.S0 I •- ------- ---
SEPTIC TANK,SEEPAGE PIT OR
1 PITS AND/OR DRAINFIELDcr` $`3.00 —..-- --- - --_. ---- -----
---1 -OVERFLO-- - ddEEPA�EPIT,- ----DRAINF[ELD- ----- - — T
� ' P, C, NO.
EXTN-,CESS OOL,DRYWELL,MANHOLE c;,-S 2.00! CO. IMdP Nq. JOB N0.
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM _ (s, S 1,00 ( I TRUNK PERMIT NO R,1AD PERMIT NO..
CONNECT ADDITIONAL Bi-DG.OR STATE ENCROACHMENT
_WORK TO HOUSE SEWER r' 31.00 I PERMIT NO.
j ALTER,REPAIR OR ABANDON HOUSE - -- --- INDUSTRIAL_-_-- -- - -SEWER OR.rISPO5AL SYSTEM _ 01, $1.00 WASTE APPROVAL
__ -- CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT 1 00 — — —— —_ ----------------
AUTHOIIIZATION TOTAL FEE --- --- - REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH. THEHEREIN NAMED CON- APPROVALSI DA'L'E IINSPECTOP SSIGNA URE
TRACTOR To CONNECT THE ABOVE DESCRIBED EXISTING DWELLING �-
TO THE PUBLIC SEWER, NEW HOUSE SEWER I.
SIGMED THIS __-DAY.OF -- -----
---�----�-�- CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK
—
OWNERS --
"-- SEPTIC TANK,SEEP,PIT($) I
-ADDRESS _ `AND/OR DRAINFIELD__.____.._.--�------,I.--
---- -- _ .— .-_ - ..D THIS
-CESSPOOL❑ DRaV'F.LL-C--- I ---.-..- ----
i HEREBY ACKNOWLEDGE THAT I HAVE READ THI,; APPLICATION
AND STATE THAT THE ABOVE. IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNT'( ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR.,SEWER OR
i
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
---
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR _
LICENSED AS REQF:IReD B.Y LO
S ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND
ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIAL...PROPERTY: BACKFILL SEPTIC TANKS(_!
SEEP.PIT(S) L. CESSPOOLS El
SIGNATURE >' °'..:;t ---T-- ------- -I----`-`----------._..-.._...-..---..
OF PERMITTEE.
I.
JOHN A. LAMBIE,COUNTY ENGINEER VALIDATION ROBERT A.WOOD,CHIEF PLBG, INSPECTOR
CK. BI.0. CASH
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