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76A642 0'62 D APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER–SEWAGE OISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILD NG
JOHN A. LAMBIE, County Engineer ADDRESS Ve
WILLIAM A. JENSEN, Supt of BuRding
LOCALITY %r
NEAREST
FOR APPLICANT TO FILL IN -CROSS IT.
LEUAL
LOT NO. OWNER
MAIL
BLOCK TRACT T f
ADDRESS
NO. OF BL GS.
SIZE OF LOT NOW ON
LOT CITY TV_ NO.
USE OP
5"JILD1"169 DISTRICT NO. GROUPBX P
MAP $ED BY
PG
CONTRACTOR
!ew—r–_
"tROCE5
ADDRESS CONNECTION DATA
5,T,A/T;QN DEPTH
_CITY n- TEL NO. Cr i '4020 1�1,
0
STATE MANHOLE REFERENCE
REG IS COUNly
6ESCRIPTION OF WORK FEE ---'I-YPF-OFCONN E-OtfQN LENGTH FROM —-----
Q.
HOUSE SEWER CONNECTING TO Y . C v k V, P.L� M.)_ TO P.L,
PUBLIC SEWER @ $5.00
SEPTIC TANK.SF.EPAGE PIT OR PC,NO,
JOB NO.
ANP/OR DqAINFI:LD -Co.IMP.N ___�
HO U SE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. 0
PRIVATE OiSPOSAL SYSTENM S3,00
LU
__F�O&NECTALD_Dl NONAL BLDG.OR A_FFI.AVIT I WMVER EASEMiNT REICORD.I_N_S_TRr�OT_
--I-WORK TO HOUSE sz�iIER @ $"l.'.)O DATE
OVERT S�ERA�67-EPFT._DRAINFIELD
I EXTN.,OE SSPOOL,ORYWELL,MANHOLE @ 1". .0 z
_14tPA _? HWY,OR ST.W30ENI ING
ALTER. E AIR 6-k-A EAN 6 ON-H HOUSE
SPOSAL SYSTEM @ 3"3�00 ENC
_Ii_pR DIE TA:F RO
STATE ACHMENT
PERMIT NO
INDUSTRIAL Z
WASTE APPROVA
ZV
CHARGES
VVNER'S PERMIT
0 oo
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE 21 oo
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON Ru"URSE_mEIstT FEE
TRACTOR PTOLCONNECT THE ABOVE LESCRIBED EXISTING DWELLIL�G
- APPROVALS SPECTO
10 THE U13 IC SEW�R. DATE' S SIGNATURE
SIGNED THIS DAY OF ----
OWNER OR NEW HOUSE SEWER
OWNERS
CONNECT ADDITIONAL
BUILDING OR WORK
SEPTIC TANK,SEE ,'
�_.PITS)
lHEREBY ACKNOWLEDGE-: THAT i HAVE READ THIS APPLICATION AND/OR DRA!NFIELD
AND
STATE THAT THE AUCV !S CORRECT AND AGREE: TO COMPLY ...
WITH ALL COUNTY ORDINANCE, AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL. Ej ORYWELL
IHERESY CERTIFY THAT I AM PROPERLY 'REGISTERED ANO/OK ALTER,REPAIR,SEWER OR
LICENSED AS REQU iREO BY 1-05 ANGLES COUNTY AND STATE Or SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR T�4AT I AM, 'THE LEGAL OWNER OF, AND INTEND TO
RE
SIDE IN. T'�.F :ABOVE
,BOVE DESCRIBED RESIDENTIAL PROPERTY. ABIANDON HOUSE'G.SEWER
SIGNATURE
OF PERMITTE.F.--L BACKFILL SEPTIC TANKS
S4'.EP.P[7(3) ID CE`_$POCLS Cj
-NALIDATION ROBERT A. WOOD
CK. M.O. CASH SUPERVISING MECHANICAL ENGINEER
6
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::E808 10-62
76A6420 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
A D OR r 51
JOHN A. LAMBIE, County Engineer 0_c_ 1 -v e
WILLIAM A. JENSEN, Sup'i of guil-fing
LOCALITY
NEAR
CROSS ST, ar
FOR APPLICANT TO FILL IN
DESCRIPTION LOT NO. OWNER
MAIL
BLOCK TRACT ADDRESS
NO. OF BLOGS,
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF
DISTRICT NO. GROUP PROCESSED BY
SUILDINGb MAP
BK PG
U
CONTRACT
Z
ADDRESS
CONNECTION DATA
CITY Q STATION DEPTH
TFL,
A
L
N
,IT
C
Y
I
OWNER L
A
ADDRESS
N
A
C,
Y
T
L
ST I N
M; ____UPPER
STATE REFERENCE >-
REG jSLrRAT.QN NO. COUNTY
--DESCR I PT_I_ON OP WORK FEE-NO-,-� --- -- 0
YPE OF CONNEr LENGIH FROM
NTINGENiR-�6NNEETTNGTO L� M.L.M.L TO P-L.
HOJSLIC SEWER $5.00 F
P.C.NO.
NOEPT , JOB NO. 0
FIT&AND/0 A.D ca IMS.
R DRAINF'fIE 0
HOUSE SEWER CONN%EcT.,4-" DRUNK PERMIT NO, ROAD PERMIT NO.
PRIVATE WSPOSAL SYSYF.M @ $3.00 LU
F OL
CJD'N F CT ADD I r�0.4 A'L BUDG-. -N-0. "DATE
'WORK TO HOUSE SEWER $3,06
i z
OVERFLOW SE:EPAGE PIT,DRAiNFirE6
EXI-N'.,CES-,PQOL.,DRYWELI-,MAWHOLE @ 35,00
iAL`Ifk,--- ---- - - ---- ---11 HWY.OR ST.WIDENING
i REPAIR OR ABANDON HOUSE
SCIVER OR D15POSAL SYSTEM W3
$lATEENCROACHMENT
PERMIT NO
INDUSTRIAL
W STE APPROVAL
C d(J I e
CHARG S
OWNER'S PERMIT
----- -------- CON NCTION CHARGE FEE
AUTHORIZATION TOTAL FEI
HAVE AT THIS DATE A CONTRACT W)rH THE HEREIN NAMED CON-
'�T THE ABOVE DESCRIBED DWELLING
TRACTOR TO CONNE EXISTING
TO THE PU6LIC SEWER. APPROVALS DATE: I 1145*ECTOR'S SIGNATURE
SIGNED THIS CIF--------l9— T
OWNER OR NEW HOUSE.SEWER
OWNERS AGENT—-------- CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
SEPTIC TANK,SEEP,PiTfS) I
I HEREBY ACKNOWLEDGL THAT I HAVE READ THIS APPLICATION AND/OR DF.AiNFIELD
STATE TATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY
WITH JALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLU Me ING ANDSEW L RS. CESSPOOL DRYWELL ❑
IHrREBY CERTIFY THAT I AM RROp ENCOUNTY ALY REGISTERED R
ANO/OR ALTER, EPAIR,SEWER OR
LIC-FNZiED AS REQUIRED BY LOS ANGI-FS SEWAGE DISPOSAL SSTM
C ND STATE OF DISCONNECT 6i�_ __O---- Y—D
E
ALiFORNIA OR THAT 1 AM THE LEGAL OWNER LSP SAND INTEND TO I N ECT PLUG AN
RESIDE IN. THE ABOVE DESCRIBED RESIDENTIAL ABANDON HO USE SEWER
SIGNATURE
OF PERIM"TTEE • BACKFILL SEPTIC TANKS
SEEP,PIT(S) EJ CESSPOOLS [31
YALIDATION
ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
cK
M.O. CASH
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