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5 E-66-663 11.55 � 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. C_AMBIE, COUNTY ENGINEER ---- - ° ----
�' CASSATT D. GRIFFIN. SUPT OF BUILDING LOCALITY 'y �"•'
NEAREST
_ FOR APPLICANT TO FILL IN
LEGAL ---- ----- -----'----------- =-_— .,t' .' '�" �.
DESCRIPTION_ LOT NO. - OWNER ----
---
BLOCK TRACT MAILADDRESS v •�"° '` >�� .
NO.OF BLDGS.
._SIZE OF LCAT CITY
NOW ON LOT _.
USE OfT
BUILDINGS_ y._<5...'w,° - i GROUP BK MAP PG
- I DISTRICT N0,�-
ACONTRACTO
ADDRESS CONNECTION DATA —
CITY � TEL. NO.. J �_ _STATION- DEPTH
-- .: -' - ------ l-_--. L
------,�1,�.. AANHOLE REFERENCE UPPER
) ,STATE
REGISTRATION_NO. + ,f z' Z' COUNTY
COUNTY
NO. } DESCRIPTION OF_WOR FEE -_ -. - ----------
HOUSE SEWER CONNECTING TO - TYPE OF�CTIO.N LENGTH FROM
1 I e Y, CURB t P.L. M.L.TO P.L.
�_I PUBLiC_SEWER-- - - -@$3.SU_, _ .,V -------- ..
SEPTIC TANK,SEEPAGE PIT OR
-_-I PITS AND/OR DRAINFIELD._-- Ca_$3_000 -_----
OVERFLOW SEEPAGE PIT,DRAINFiELD ---fff P C N0.
EXTN.,CESSPOOL,DRYWFLL,MANHOLE (4i$2,00 -J - a',O, IMP. NO. }�' _-�' ,9 JOB NO,
I HOUSE SEWER CONNECTING TO I ~-
PRIVATE DISPOSAL SYSTEM ((SS 1.00 I R(;N1{ PERMIT NO. - ROAD PERMIT N0.
--- ---- ----- - ---- ..-..----__
CONNECT ADDITIONAL.BLDG.OR STATE ENCROACHMENT
WORK TO EIOUSE SEWER ((t) $1_00 I 4 -- PERMITRIO�
ALTER,REPAIR OR ABANDON HOUSE !
AL
SEWER OR DISPOSAL SYSTEM (x_$1..00
WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNERS PERMIT 11 Ob
AUTHORIZATION TOTAL FEE ErMBURs>MENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE KEREIN AMED CON-• APPROVALS � DATE �INSPE.CTOR'SSiGNATURE
TRACTOR TO CONNECT iE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEW n NEW HOUSE SEWER
SIGNED THIS --- '� DAY OF L d, lo„
, T w CONNECT ADDITIONAL
OWNER OR 1rrr�,� �r BUILDING K,WORK
OWNERS ORENT. "Z ^: ev -_—.----
�-* SEPTIC TANK,SEEP,PIT(S)
ADDRESS AND/OR DRAINFiELD _ -�--
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL L DRYWELL❑ — {
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR I I-
PLUMBING AND SEWERS. _SEWAGE DISPOSAL.SYSTEM I _
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND -
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF
CALIFORNIA OR. THAT I AM THE LEGAL OWNER OF-.,THE. ABOVP ABANDON-HOUSE SEWER
S,CRI'gD RES}}}'''DDDENTI L PROPER ,y�,• ,�, BACKFILL SEPTIC TANKS Lj - !'
SEEP. PIT(S) ❑ CESSPOOLS['}-^I_- ---.. ' - ----
JOHN A. LAMBIE,COUNTY ENGINEER VALIDATION R(DBERT A.WOOD, CHIEF PLBG. INSPECTOR
CK. Id.0. CASH
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