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'6A 6420 -CEBOB-10-71 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-S AGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING ( !
ADDRESS
LOCALITY .__� ` tyt,. ✓J L' 4 _.�-'✓.___-
NEARE57 �f
FOR APPLICANT TO FILL IN CROSS
LEGAL
DESCRIPTION LOT NO. OWNERJt'
MAIL ;/ If
BLOCK TRACT �^ IG ADDRESS , r Idv
NO. OF BLOGS. �E ," TEL. NO.
SIZE OF LOT NOW ON LOT �� CITYj (.,��,:rV'-
USE OF DISTRICT NO. GROUP MAP �2CESSE BY
BUILDINGS ° � }"�l' SK PS
CONTRACTOR '` 1"Isi) 4A� ..6z . _ 6.� I -16, ,7a...+l�+�
ADDRESS a " sa %'�C t� ��Fa CONNECTION DATA
,f /may, jyy STATION 2._,i. DEPTH
CITY f.A7�.''. %7 TEL. NO. j t'- ,�' /
STATE o f LIC fry 0 l� ,�j MANHOLE REFERENCE
LICENSE_NO, 3 CLAS$ '4 --`-� �' , `'6 ll"
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION ,, LENGTH FROM .•S
HOUSE SEWER CONNECTING TO Y. CURB M.L.TO P.L. G°
PUBLIC SEWER $7.00
SEPTIC I'ANK.SEEPAGE PIT OR P.C.NO.
PITS AND/OR DRAINFIELD $10.00 CO.IMP_N O.
JOB NO.
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. 0-
PRIVATE DISPOSAL SYSTEM @ $3.00 O
p CONNECT ADDITIONAL BLDG.OR ;i AFFIDAVIT k'AIVER Ea4E M[xt RECORD.INSTR.NO. DATE V
/ y�S OU SE SEWER $3.00 (J
OVERFLOW SEEPAGE PIT.DRAINFIELD _
EXTN„CESSPOOL.DRYWELL, $5.00 O
ALTER,REPAIR OR ABANDON HOUSE _ HWY.OR ST.WIDENING (-
SEWER OR DISPOSAL SYSTEM $3.00 _ STATE ENCROAC.11 f T f” j-f (� U
$7.00 PERMIT NO. L.C'Y'`1-".r'd3,=.... �S- 41 N
MANHOLE _
----- INDUSTRIAL -y
WASTE APPROVAL L
CHARGES
OWNERS PERMIT $ 3 00
AUTHORIZATION TOTAL FEE �) CONNECTION CHARGE FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWEQ ...-= APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS. t—DAY OF `• � 19
OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL
BUILDING OR WORK r� -f 'd"�,t.•'L-g�:y..^
ADDRESS__ -
SEPTIC TANK,SEEP,PITS)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR T AM THE LEGAL OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE A!B VE ESCHIBESI ENT AL PROPERTY. ABANDON HOUSE SEWER
9
SIGNATURE r r ` BACKFILL SEPTIC TANKS ❑
OF PERMfTTEE iYr .�"' ��' m-` �' - --__— SEEP,PITS) ❑ CESSPOOLS ❑
VALIDATION CK, M.O. CASH
S7qui 9 Lv 0 6.v0A-