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APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE_ D r SPOSA L
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION sUILDING a �,` L j4_�.
A DDRES:S
JOHN A. LAMBIE. County Eng ineea
WILLIAM A. JENSEN, Supt of Cld'zng LOCALITY
FOR APPLICANT TO PTCI. IN CROSS ST.
LEGAL OWNER
DESCRIPTION LOT N0.
MAIL
BLOCK TRACT ° •- H ' ADDRESS
NO.OF BL GS.-�7
S17E OF LOT NOW ON LOT CITY TEL. NO.
USE OF
BUI.I.6ING,S �` +ter••-- DISTRICT N0. _GROIiP $� -MAP P� p�S�D SY �
CONTRACTOR
^p `"">. %
s
ADDRESS , 3 ,_s / '-,, ) '-' CONNECTION DATA
CITY TEL.N0. <.,. / `atPP T TION
DEPTH
-{f-
c^ " `
Jnr , ° STATE MANHOLE REFERENCE ,s„f f '
REGISTRR7ION NO. _;�f '"' _- COUNTY �F i f}s -'`"LOWER
NO. DESCT;I.PTI N(3 OF
WORK FEE
HOUSE S WER CONNECTING TO �,,�'"'%'
PUBLIC SEWER CO $3.00 TYPE OF CONNECTION _
. LEIIG__TH FROM
SEPTIC TA«K,SEEPAGE PIT OR Y. CURB P,L. M,L.TO P.L. °
ITS AND.ICR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT,DRAFNFI.EL.D
EXTN..CESSPOOL.DRYWELL @ $2.00
HOUSE SEWER CONNECTING TOP.C.N0,
PRIVATE DISPOSAL SYSTEM Cb 51.00 CO.IMP. NO. "�' JOB NO.
CONNECT ADDITIONAL BLDG.OR �i W
WORK TO HOUSE SEWER @ $1.00 TRUNK PERMIT NO. ROAD PERMIT NO. �/`� _`^ � `/� _p
ALTER. REPAIR OR ABANDON HOUSE .STATE ENCROACHMENT
I�S�EEWER OR DISPOSAL SYSTEM @ $1.00 PERMIT NO
�I
INDUSTRIAL
WASTEPR
ASTE APPROVAL p�
CHARGES
OWNER'S PERMIT S 22 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE T o REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATEINSPECTOR'S SIGNATURE.
TO THE PUBLIC SEWER. -a-
SIGNED THIS DAY OF 19- NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL �.
OWNERS AGENT 'PAC", BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PIT($)
AND/OR GRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL CI DRYWELL CI
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. ALTER,.REPAIR,SEWER OR
SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT T AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND ST'AT'E OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIAC PROPERTY. BACKFILI,SEPTIC TANKS
SIGNATURE �r r S EP.PIT( CESSPOO S C]OF PERMITTEE '
�r7 VALIDATIOROBERT A. WOOD
CK. 9.01 CASR~ SUPERVISING MECHANICAL. ENGINEER.
APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING .
JOHN A, LAMBIE, County EngineerADDRESS C f
WILLIAM A. JENSEN, Sup'!of Building LOCALITY
FOR ,APPLICANT TO F= IN CROSS sr. X f
LEGAL OWNER 'PAY a
DESCRIPTION LOT N0. �^
BLOCK TRACT °_. MAIL
ADDRESS
NO.OF BLDGS.
SIZE OF LOT NOW ON LDT CITY --^ EL NO
USE OF
BUILDINGS /A- DISTRICT N0. GROUP MAP PROCESSED BY
BK P6
CONTRACTOR r� ...w '•�+� ... ,y � �; � r '' - !,' i, . P,
E i
ADDRESS P , A F CONNECTION DATA
CITY TEL N4. �, l ��-M. C �- ` s `� iN A" _..' DEPTH ;
a{ STATE MANHOLE REFERENCE /� s j -
REGISTRATION NO. / ® COUNTY f 1 LOWER
NO.-NO.A DESCRIPTION OF WORK FEE -
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3,00 _ — _ w H
SEPTIC TANK,SEEPAGE PCT OR TYPE OF CONNECTIO P LENGTH FROk
Y
PITS AND/OR DR.AINFIELD $5.00 Y. CURB P.L. M.L.T6 P,L.
OVERFLOW SEEPAGE PDT,DRAINFIELD '-mega .^ _
EXTN..CESSPOOL.DRYWELL @ $E.00
HOUSE SEWER CONNECTING TO P.C.NO. O
PRIVATE DISPOSAL SYSTEM @ SLOO CO.IMP.NO. JOB NO. V
'
p CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT N0. ROAD PERMIT NO. / n
I WORK TO HOUSE SEWER @ St.00 'Z
ALTER,ORREPAIR OR ABANDON HOUSE STATE ENCROACHMENT
S R DL§FO2AOYSTEM @ $1.04 PERMIT NO. V
F. INDUSTRIAL a
WASTE APPROVAL N
CHARGES z
�+tO��S" PERMIT $ _ffiCONNECTION CHARGE FEE
A�iV lHOPUATION, TOTAL FM .2 C 'r REIMBURSEMENT FEE
MED CON.
TRACTOR TO CCONNECT THE ABOVE DESCRIBED EXIISTINGDATE A CONTRACT WITH THE HEREINADWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER,
SIGNED'TEAS DAY OFA I9_ NEW HOUSE SEWER
OWNER OR f--, CONNECT ADDITIONAL
OWNERS AGENT a" BUILDING OR WORK I
ADDRESS SEPTIC TANK,SEEP.PIT(S) I �I
AND/OR,DRAINFIELD R i
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY CESSPOOL DRYWELL ❑
WITH ALL. COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS, SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT i AM PROPERLY REGISTERED AND/OR 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.PFtPPERTY. BACKFILL SEPTIC TANKS
SIGNATURE SEEP.PIT(S)" [] CESSPOOL
OF PERMITTE -
VAIMATION ROf3I=RT A. WOOD
CK. H.O. 7CASR l SUPERVISING MECHANICAL ENGINEER
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