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7SA642D APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER SEWER-SEWAGE DISPOSAL
BUILDING AND SAFETY DIVISION I
JOHN A. LAMBIE, County Engineer ADDRESS
WILLIAM A. JENSEN, Sup't of Building
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL- OWNER
DESr-RiP-ION LOT NO,
MAIL
BLOCK I RAC ADDRESS
L GS,
OF 9
SIZE: OF LOT NOW ON LOT CITY TEI NO.
----E -F-
us 0-
BUILDINGS DISTRICT NO. GROUP MAP PROCESSED BY
13 K PG
CONTRACTOR
ADDRESS .v-... -CONNECTION DATA
CITY TEL NO. STAilo' j",
STATE:
RFG)SijRATIO!q NO Coc.wl MANHOLE REFERENCE
OWER
F -IW-0 R K FEE: --y
NO. DESER'FiTION OF OPSN �Hl
1 1;N LE
HOUSE SEWER CONNECTING TO P.L. M.L.TO P.LDM
PUBLIC SEWER Ss CO
SEPTIC TANK,SEEPAGEPITOR
PITS AND/ORDRAINFIELD @ 510.00 -CO.1 MP,NO, 31
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT No) 0
PRIVATE DIS OSAL SYSTEM $3.00
RECORD. INSTR. NO. DATE:
CONNEC�ADDITIONAL BLDG OR AFI�IDAViT FINAIVER E&SEMCNT
WORK TO HOUSE SEWER @ $3.00
OVERFLOW SEEPAGE PIT,GRAINFIELD
1 EXT14.CESSFIOOL.DRYWELL..MANH-C)'V @ ss.00
HWY.OR,T,.� I
ALTER.R ABANDON HOUSE
REPAIR W OR T
E_'N
-SEWER OR DISPOSAL SYST Em @ $
-00--i STATE
RO CHME
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
O "s PERMIT
CHARGES
WNER IT
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NA-EO CON- REIMBURSE-M-ENT FEE
TRACTOR TO
CC*q E
NECT THE ABOVE DESCRIBED XIST;NG DWELLING
TO T H E P JBL.fC SEWFR,
APPROVALS 0A7E i I NSPt CTOR'S 5 I GNATURF.
SIGNED THIS DAY -
ONNER OR
NEW HOUSE SEWER
OWNERS AGENT—-
CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
SEPTIC TANK,SEEP,,PITS)
H ERE13Y ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR GRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGRE:F_ TO COMPLY
WITHALL COUNTY ORDINANCES AND STATE: LAWS REGULATING
1
HEREBY CZRI71FY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR.SEWER OR I
PLUMBING AND SEWERS
RS. CE SPOOL L-I DRYWELL
L 1 Y
-ENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
'D - - —
ALAN
FORIA OR THAT Z AM TLHE LEGAOWNER OF, AND INTEND TO ---DISCONNECiPLUG AND
RESiDE IN, THE ABOVE,DESCRIBED RESIDETIAL RR�WERTY, ABANDON HOUSE SEWER
,GNATURE
OF PERMrTTEE 1ACKFI1-L SEPTIC TANKS El I
SEEP iT(S) [I CESSPOOLS Ell I
VALIDATION - ROBERT A. WOOD
CK. M.O. CASH SUPERViSING MECHANICAL ENGINI--ER
CEa3B3-fi APPLICATION F6R PERMIT
?BAfi.A2b
COUNTY OF LosANGELESTYGI SEWER- SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUaILDING AND SAFETY DIVISION FNEARE
G
It�fIN A. LAMBIE, County Engin®ea ADDRESS
.
MW
WILLIAM A. JENSEN, Supt of Building
Y
FOR APPLICANT TO FILL IN T
-__I EGRL
DESCRI}T10N _LCT NO --/"J .]r ,,,g ., OWNER -
MAIL
BLOCK TRAIT � � -. -=gA--` ADDRESS
NO. OF SLOGS
SIZE OF LOT NOW ON LOT CITY '^F. "'TEL. NO_
USE OF
BUILDINGS DISTRICT NO. GROL`P MAP PROCESSED BY
CONTRACTOR
y
I
ADDRESS - _—p� N xiaN DATA
E
CITY AT!ON �.._ a
TL NO.
7
'? 5TATE M.4NH..OLt REFERENCE
REGIS RATION NO C'U NT.l` ,•-'� f .. .. .
No, l DESCRIPTION OF WQRK FE£ - _ n t L ,F CONN CT i LENGTH FROM
HOUSE 5 EW_ER-CONNECTING TO Y. P.L. M L 30 P.L.
PUBLIC SEWER @ Ss.0- _.= ,f`.
I I
--._ ._-- --- - __- --.__ "- C.NO
EPTIC 7ANK SEEPAGE PIT PIT OR P'
'Oi}AP NO. JOB NO
PITS AND/OR DRAINFIELq C $iO.00 ._._
HrJu5E SEWE}?c ONNE Ti NG:TO TRUNK PERMIT NO. ROAD PERMIT'*1 tt
1 PRIVATE.DISPOSAL:SYSTEM Cm 53;00 1
r_
.._r-._—_
CONNECT ADDITIONAL BLDG OR - � AFFICAVIT ; WAIVER! ER3EM ENt IRECO RD.INSFR NO.
WORK TO HO SF SEWER $3.00
-- - L - - --- - --r - -- _
OVERFLOW SEEPAC E PIT.O,MAI FH Et_D HWY.OR SYS.. -
EX7N,CESSFGO CRYWkLL,MA HOL.E� $5-.OU ' -�-
___ I .WICENING
ALTER,REPAIR O.R AHANDO,� JSE
SEWER R_OR DISPOSAL 5 T Mr C� $3:03 - -. -._. _ _-
--- - -- STATE.FN POACH MENT
I PERMIT NO
INDUSTRIAL.
WA-5T E A YROVA r _I
_p
__. ___.._-_-.. CHARGES
OVSTNER'S I�EIMIT .. --- --- - --- ---- - - -- - -- -
-- - - -- --
CONNEITIOIV CHARGE FEE
AUTHORIZATION TaTAL FEE ��="'� ��Z�
I HAVE AT II-HS DA'F'E A CONT'RAC'T WITH THE HEREIN NAMEO CON- REIMBURSEMENT FEE
T.R ACTOR TO ONNE;T THE.ABOVE DESCRIBED EX:STING DWELLING -- APPR®VALE ------
DATE iPd-1PECTOWS SIGNATURE
TR T'HE PUC9LI_ ST=NER. T,11
THIS----DAY OF_ 79 ------ - - "-- -- --- - ---
OWNER OR NEW HOUSE SEWER
OWNERS AGENT--- CONNECT ADDITIONAL
RU6.LOING OR WORADDRP K
—_ ETIF.TANK,SEEP,P17(S)
'
HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICAT!ON i
AND!vR UR AtN$'ESD
AND STATE THAT :HE ABOVE IS CORRECT AND AGREE TO COMf`LY
WITH ,ALL COUNTY ORUINANCIFS AND STATE LAWS REGULATING I
PLUMB INC AND.SEWERS. CESSPOOL., D URYWELL
t HERE HV CERTIFY THAT I AM PROPERLY REi515'f ER Et} AND/OR ALTER,REPAi R,SE Jv ER OR i
LICENSED' AS REQUIRED BY LOS ANGLES COUNTY .AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORh11A OR ?HAT .,AM THE LEGAL OWNER OF AND INTEND TO ""--
DISCONNECT PLUG AND
RESIDE IN, THE f1BVg' 6ESCRIBEO RESIDENTIAL PROPERTY,
ABANDON HOUSE SE—
SIGNATURE
OF PE:RMT'1"KEE4_ —_—____ / 'BACKFILL.SEPTIC TANKS L 1
--� �`! SEEP,PIT(5) ❑ CESSPOOLS []I
VALIDATION.- ROE3ERT A, Wood
CK. M. o_ CASH SUPERVISING
SUPERVISING MECHANICAL ENGINEER
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