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'S9. 6APPLICATION FOR PERMIT
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COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS �—
COLEMAN W. JENKINS. SUPT. OF BUILDING k
LOCALITYf
NEAREST
APPLICANT TO FILL IN cRoss ST-
(PRINT
iPRiNT OR 'TYPE ONLY; _ ..^ �°"^ �-�—�^'�-r.,
LEGAL
D.ESCRIPTION_____ LOT NO "E,' ,L+` — OWNER
MAIL
BLOCK TRACT ri ✓✓ ADDRESS -
NO. OF BLDG5.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
Oi5 TRdCT NO. GROUP t;LASS AP PA�t
BUILDINGS " -- M .�
CONTRACTOR / � J
ADDRESS CONNECTION DATA
�-
CITY _ TEL. NO. STATION DEPTH
STATE LIC.; MANHOLE REFERENCE
LICENSE + -- -
L NOCLASS
w
No DESCRIPTION OF WORK FEE -- TYPE YPE OF ---
CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO +Y� CURB P,L. M.L.TO P.L. 5
PUBLf C_SEWER @ $5,00 + � ---- ----� y
-..__. ._P "} �1 P.C.NO.
SEPTIC D/ SEEPAGE P17 OR . f J :)
JOB NO.
PITS AND/OR OR ORAiNf IEI_D @ $f0.00 COIMP NO_.._—� --�.— .-_..---_--
NOJ E S WER CONNECT NG TG 0-
7 PRIVATE D15POSAL SYSTEM -----@ $3.00— — — ROAD PERMIT NO. -�3 '�)J Cy^ 0—
PRIVATE.
PERMIT Fi O. �*
�} ONNE<"I ADD(TiON0. BLDG OR AFF(DAVIT wR(YCR cA'£ME MT ' RECORD.iNSTR.NO. DA
TEy
l WORK TO HOUSE SEWER @ $3.00
_-. — -176
__——
OVERFLOW SEEPAGE PIT,gRAiN FIELD _ L --- 4°
—. EX'TN.,CESSPOO(_.DRYWELL.MANHOLE@ $5.00
._-__._.._____._—__.—._ __. --_—_ �.._ HWY.OR ST.WIDENING.
ALTER.REPAIR OR ABANDON HOUSE I
SEWER OR DISPOSAL SYSTEM @ $3.00 — --- ----- --- — - ------ (�
-- __._ L._ STA TF_'ENCROACHMENT
J
PERMIT NO. CL
INDUSTRIAL V)
WASTE APPROVAL. z
CHARGES
OWNERS PERMIT -------$ oo - ----
AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEE_ �� ->� ---_
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREINNAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE. ABOVE DESCRIBED EXISTING DWELLING --- T¢ `
TO THE PUBLIC SEWER. Ali'PR Aia<w7 DA INSPEC S SIGNATURE
SIGNED THIS_, DAY OF.--19—
OW NER
F19_.,OWNER OR NEW HOUSE SEW - �^''~'
OWNERS AGENT O--- -
CONNECT ADDITIONAL
ADDRES BUILDING OR WORKS _ _ _- __
— --- — - SEPTIC TANK.SEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE 'TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE. LAWS REGULATING
Pt_UMBING AND SEWECESSPOOL RS. ClDRYWELL
❑ I
I HERESY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR.SEWER OR*—
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT i'AM THE LEGAL OWNER 09, AND INTEND TO
q SCONNECT PLUG AND
RESIDE IN,. THE ABOVE DE'iCR I.BtiO RESIDENTIAL PROPERTY. - -- J —
ABANDON HO
VSE SEW ER
SIGNATURE �.-
-_ ___— BACKFILL SEPTIC TANKS
OF PERMt°TTEE_..__...____—____._.___.._. —.___— SEEP.PIT(S) ❑ CESSPOOLS ❑
YAUDATION JACK R. ALLEN
CK. ,' Md fl. CASH SUPERVISING MECHANICAL ENGINEER
_ �..
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