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:A6420
6A6420 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
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JOHN A. LAMBIE, County Engineer REf W;r /V c elto foe-
WILLIAM A. JENSEN, Supt of Building
LOCAI TY I-e
..EARES
FOR APPLICANT TO FILL IN
DESCRIPTION LOTNO. OWNER
MAIL
BLOCK TRACT ArDRE--
NO. Or BLDG s,
SIZE LOT 0 OW ON, LOT' CITY 25eA TEL. NO.
USE
DINGS
DISTRICT MAP PROCIESSED BY
BU 'T
0 'UT
CONRACTOR 1_1;7'�T
ADDRESS CONNECTION DATA
CITY TEL- NO. STA TI 0 N
DEPTH
.
UPPER
STATEMANH'.OL'_REFERENCE
REGISTRATION NO. ❑ COUNTY LOWER
TYPE OF CONNECTION LENGTH FROM
—
No. DESCRIPTiON FEE
S7EWE_R 60NNECTING TO I Y. CURB P L. M.L.TO P.L.
PUBLIC SEWER @ 35.0!7 P.C.NO.
SEPTI-C TANK,SEEPAGE PIT OR JOB NO0
/OR DRAINrIELD
PITS AND @ SIOOO
HOUSE SEWER CONNECTING TO TRU K PEFIMIT PERMIT NO,
PRIVATE DISPOSAL SYSTEM. @ $-'4.00 ge
C �r Ac 5-- VER! EASf.MENT
ONNED ADC-IT I c N AL BLDG RECORD.INSTR.NO.T__DAT1 0
IN ";I
WORK TO HOUSE SEWER $3.00
OVERF LOW SFEPAGEPIT 0_RAT_N_F_1_E_LD`___
EXTN_CESSPOOL.DRY'�E'LL.MAN HOLE @ S5.00
------ HWY.OR ST.WIDENING
ALTER.REPAIR F?ABANDON HOUSE 4n
SEWER OR DISPOSAL SYSTEM @ $3.00 -Z
PERMil NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNER'S _ PERMIT-
S: 2[ 00
-- CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE __F__ , 11 i - . __
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
T RACTOR.L0,CONNECT THE ABOVE DESC9IDED EX°STING DWELLING
- ' j DATE INSPECTOR'S SIGNATURE]
To THE B410 SEWER. APPROVALS
SIGNED THIS—_DAY
OWNER OR NEW HOUSE SEWER
OWNERS AGENT______.
CONNECT ADDITIONAL
B, LDING OR WORK
ADDRESS_-
SC-TIC TANK.SEEP,PIT(S)
I HEREBY ACKNOWLEDGE. THAT I HAVE READ THIS APPLICATIONAND,'CR DRAINFIELr)
AN STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS, CESSPOOL. DRYWELL rj
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER.REPAIR.SEWER OR
LfCKN AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF 5 EWAGE DISPOSAL SYSTEM
VSTE M
CAi-IFORN A OR THAT 1 AM THE LEGAL OWNER OF. AND INTEND TO
DISCONNECT PLUG AND
RESIDE IN, THE ABOVE DESCRIBED RESIDENTIAL PROPERTY,
ABANDON HOUSE SEWER
SIC NATURE
OF PKRMTTTFzBACKFILLSEPTIC TANK'
SEEP PIT(S3 CESSPOOLS ISI
VALIDATION_-., ROBERT A. WOOD
CK. M.O. CASH SLIPERVISiNG MECHANICAL ENGINEER
Lj�c)1 5 2 0 Za' JUL 18 1 0 D 5.0 0-