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808 11-57 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION "UL NG
SS C kve.-�n -7
JOHN A. LAM ITE, County Engineer ADDRESS 62 ) McCul
CASSATT D. GRIFFIN, Supt of Building
LOCALITY (�IIYCII�E_'ll C'ity
EAREST
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL
Tl
DESCRIPTION LOT NO. 15 OWNER c c 'j
ZU
BLOCK TRACT MAIL iJeA
ADDRESr'
NO.OF BLDGS,
C'n TEL.NO.
SIZE OF LOT NOW ON LOT CITY
USE OF
UILDINGS-_�cr�'lj
L, DISTRICT NO. GROUP MAP
PG
CONTRACTOR Ii 0 rl"S t r'a C c_
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ADDRESS Box 203 CONNECTION DATA
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N0.CITY � Fjr. PnJ,:j�7 TEL.N STATION DEPTH
I e • - i at, Z" " -
REGISTRATION NO. STATE, MANHOLE REFERENCE
COUNTY
z Z :t
NODESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO 00
PUBLIC SEWER TYPE OFCONNECTION,--,-,�4
SEPTIC TANK.SEEPAGE PIT OR Ml.�LN.GT"HIFR
L?
—PITS AND/OR DRAINFIELD @ $3.00 Y. CURB L. f,
OVERFLOW SEEPAGE PIT-DRAINFIELD
EXTN.,CESSPOO L.DRYWE L L,MAN HOLE @ $2.00
HOUSE SEWER CONNECTING TO P.C.NO.
PRIVATE CO.IMP.NO. JOB NO.
)NNECT ADDITIONAL BLDG,OR
'WORK TO HOUSE SEWER @ $1.00 TRUNK PERMIT NO. ROAD PERMIT NO.
ALTER,REPAIR OR ABANDON HOUSE
_.SEWER OR DISPOSAL SYSTEM @ $1.00 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OMMER'S PERMIT 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL 1 ME C 5 '10 0 REI MBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON.
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE JINSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS DAY OF-----,—,l 9_ NEw HOUSESEWER
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 F-1 DRYWELL Ej
WITH ALL COUNTY ORDINANCES AND STATE LAVIS REGULATING
PLUMBING AND SEWERS. ALTER,REPAIR,SEWER OR
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR --SEWAGEDSPQSALSySlEM
LICENSED AS REQUIRED BY LOS tlGELES COUNTY AND STATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT I AM -TIVE LEGALOWNER OF THE AjiI9VE ABANDON HOUSE SEWER
DESCRIBED RESIDEKS"A'y BACKFILL SEPTIC TANKS El
SIGNATURE
SEEP. PITS) Q CESSPOOLS Cl
OF PERMITTEE _8�
VAUDATION ROBERT A. WOOD
CK. ki,01 CASH SUPERVISING MECHANICAL ENGINEER