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:Ee08 8•59 APPLICATION FOR PERMIT - -
7
COUNTY OF LOS ANGELES SEWER-SEWAGi `DISPOSAL 1
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION ;NEAREST
LDING
RESS
IOHN A. LAMBIE, County Engineer
CASSATT D. GRIFFIN, Supt of uil@ing ALITY e. ("
FOR APPLICANT TO FILL IN
SS ST. f -
LEGAL
DESCRIPTION LOT N0, OWNER
BLOCK TRACT MAIL
ADDRESS Q
NO.OF BL.DGS. — r t
SIZE OF LOT NOW ON LOT CITY = E' TEL. ND. �
USE OF TIM
BUILDINGS DISTRICT N GROUP IBK PG
— MAP PROCESSED BY
CONTRACTOR
ADDRESS CONNECTION DATA
CITY TEL NO' Y STATION DEPTH
r •, STATE MANHOLE REFERENCE UPPER
REGISTRATION NO. COUNTY LOWER
NO. j DESCRIPTION OF WORK FEE -
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ 0.00
TYPE OF CONNECTION LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR I Y. CURB P.L. M.L_TO P.L.
PITS AND/OR DRAINFIELD @ 0.00 -
OVERFLOW SEEPAGE PIT,DRAINFIELD -
EXTN.,CESSPOOL.,DRYWELL @ $9.00
HOUSE SEWER CONNECTING TO .'P. NO.. -
PRIVATE DISPOSAL SYSTEM @31"'00 CO.IMP.NO, JOB NO.
CONNECT ADDITIONAL BLDG.OR
WORK TO HOUSE SEWER $1.00 TRUNK PERMIT N0: - ROAD PERMIT N0.
@ - .' �
-u�r��__�e-.-ter n.ABANDO'y HOUSE STATE ENCROACHMENT
DISPOSAL SYSTEM @ $1.06 _ ' PERMITNO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNER'S PERMIT S p 00 CONNECTION CHARGEE FEE
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
IHAVE AT THIS DATE A CONTRACT WITH THE HEEINAMED CN-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS DAY OF 19_ NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PIT(S)
_AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL Q
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER, OR '
PLUMBING AND SEWERS. _
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR SEWAGE DISPOSAL SYSTEM
DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE - -
DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS Cl
SIGNATURE a /`. _ - SEEP.PIT(S) Cl CESSPOOLS
OF PERMITTE ( r
?• / VALIDATION ROBERT A. WOOD
'C%. U.0. CASH SUPERVISING MECHANICAL ENGINEER
r
?6A$42D76A642Ds2 APPLICATION FOR PERMIT
COUNTY of LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING � -
JOHN A. LAMBIE, County Engineer ADDRESS -- --- — -- — ---_— ---
WILLIAM A. JENSEN, Sup't of Building
LOCALITY
NEAREST
FOS .�P��.IC 14T TCS EI L IN CROSS
ST — --- -
y�j _-
--LEGA.L Lr�C..— =. l
DESCRIPTION LOT�7 f `'y'""'- OWNER
MAIL.
BLOCK TRACT l d E� ` ADDRESS
NO, OF BLDGS.. _- -.. •—' ._ __—_—
SIZE. OF LOT NOW ON LOT CITY - '`.'TEL. NO
USE OF
13U ILDINGS – DISTRICT NO. GROUP M.AP PROCESSED BY
BK PG
CONTRACTOR L,T f S
ADDRESS f CQNNECTIQN.DATA
CITY ...TEL NO, _ STATION y,11-�
E.
S AT
f
REG!STRA !ON NO OUNTY! ; ' MAN.H OLE RF_FER NCE
NO DE�C-R PTI<JN OF WORK FEE _—
...L - -_ _ _ T'Y F'E OF CONNECTION ION LENGTHFROM �s
4 - t —: � CO. URB " M.L n P.4
HOUSE SEWER ONNECTING TO Y
PU 6l IC 5EV�FR
'ms_µSEPTIC TANK SEEPAGE PIT OR � Y C NO, pp y�
? IMP NO. �' .JOB NO U
i PITS AND:CR DRAIN{IELD $90.00
HOUSE"SEWER CONNECTING TO ! TRUNK PERMIT NO, ROAD PERMIT NO,---,,'
I PRIVATE DISPOSAL SYSTEM @ $3.00 s
S - $ ---;-- -- --- I v - _ -- --
(ON^(ECT AJD17:ONA BLDG.OR AFrIDAVIT WAIVER 1 EfuSfM E""JF' RE:r'ORD.IfiJSTR NO, DATE-
_ i WC RK TO HOUSG StWER -, � $3.00 y
OVERFLOW SEEPAGE PIT DRAINFIELD
i
EXT N..CE SPOOL,D RYW LL,MA NH OLE 0 55.00 I
HW Y.OR ST.WIDENING
S .
ALTER.REPAIR ORPBA NGON HOaiSE
�SEWER OR DISPOAL SYSTEM 53.00 _.
._ STATE ENCROACHMENT
PERMIT NO.
IND'J5TRIAL
WASTE APPROVAL.
CHARGES
OVVNER's hERMTT z 90 -- ----- — -- --- _..— .-------- ---
AUTHORIZATION TOTAL FEE �/ �.} ONNE Y!ON CHARGE FEE
HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- ____RE!M R5c MENT FEE
7P.RCTOP. TO CPNpdECT THE ABOVE DESCRIBED EXISTINGD4Y FEEING ----- -- - --------- ---1 -------- ---- ----
7� —,-
TO THE PUB.LI SEWER. APPROVALS DATE %INSPECTOR'S S SiGNATU RE
SIGNEDDAY OF'
OWNER OR ,. NEW HOUSE SEWER
OWNERS A3EFu7� _^ CONNECT ADDITIONAL ` �f
BUILDING OR WORK
ADDRESS___
SEPTIC TANK,SEEP PIT(5) � I
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS AI PLICA'ION AND/OR DRAINFIELO
nN1, STATE THAT THE ABOVE IS CORRECT AND AGREE ,O COMPLY - I
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING I.
PI UM8[NO AND SEWERS. CESSPOOL ❑ DRYW_LL ❑ I �`
HEREBY CERTIFY THAT IAM PROPERLY REG-ISTERED AND/OR ALTER,REPA3R,SEWER OR
LICENSED AS REU IRED By 1,OS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR CITHAT I AM THE LEGAL OWNER OF, AND INTEND 'TO DISCONNECT Pl_l AND �—_---_ ------�---
R6'SIOE IN, 7F44- ABO�VE)b E$�R.IBED RESIDENTIAL Pet OP - ABANDON HOUSE SEWER1
51 GN.ATU RE I' � �+ ____— ..-
_ _-- ___o _
-
Or PEF{M LT�TEE - BACK`FILI SEPTIC TANKS
___-_— .s 16-' SEEP,PIT(S) �'! .ESSPOOLS
L VALIDATION ROBERT A. WOOD
CK: M.O. CASH
SUPERVISING MECHANICAL ENGINEER
I