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APPLICATION FO R PERMITE808
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COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSA -�;
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION
UI
JOHN A. LAMBIE, County Engineer AD;A-1 -k"
CASSATT D. GRIFFIN, Supt of Building
LOCALITY
NEAREST
,Y
ST.
FOR APPLICANT TO FILL IN IcRDSS
- --- ------------
LEGAL
DESCRIPTION LOT NO. OWNER
BLOCK TRACT C-`gal MAIL
-13 ADDRESS
NO.OF BL GS.
SIZE OF LOT!
NOW ON LOT I CITY ------TEL.-NO.
USE OF
BUILDINGS DISTRICT NO. GROUP MAP PROCESSED BY
CONTRAday r.sa BK PG
ADDRESY-4L"q- c,--- CONNECTION DATA
NO,e- DEPTH
STATION
TATE MANHOLE REFERENCE UPPER
REGISTRATION NO. STATE
NO. 1 DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3.00
TYPE OF CONNECTION LENGTH FROM
SEPTIC TANK,SEEPAGE PIT
OR Y. CURB M.L.To P.L.
PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE FIT,DRAINFIELD
EXTN..CESSPOOL. DRYWELL C $2.00
HOUSE SEWER CONNECTING TOC N.0.
F6 0
PRIVATE DISPOSAL SYSTEM— $1.00 CO.IMP. NO, JB TI
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT NO.
WORK TO HOUSE SEWER @ $1-00
ALTER,REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
SFWER OR DISPOS L SYSTEM @ $1.00 PERMIT 740.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNEWS PERMIT 2- 00
AUTHORIZATION TOTAL FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREAN NAMED CON- �' F
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS-DAY OF NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS.AGENT UILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PIT($)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL 0 DRYWELL ❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING —A
PLUMPING AND SEWERS. LTER,REPAIR.SEVER
SEWAGE SYSTEM
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 P,4i THE LEGAL OWNER OF THE ABOVE -
DESCRIBED RESI IAL fOPERTY--aBACKFILL SEPTIC TANKS E3
SIGNATURE SEEP.PIT($) El CESSPOOLS El
OF PERMITTEEal JL-1
VAIMATION- ROBERT A. WOOD
CK. X.O. "SI, SUPERVISING MECHANICAL ENGINEER