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E•663 1t.85 APPLICATION FOR PERMIT' 1
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DIVISION OF BUILDING AND SAFETY SEWER--SEWAGE DISPOSAL
Department of County Engineer
County of Los Angeles BUILDING
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS r----
CASSATT D. GRIFFIN, SUP'r OF BUILDING LOCALITY ,, ^
FOR APPLICANT TO FILL IN CROSS ST. .
LEGAL fr` ► —
DESCRIPTION LOT_N_O ,��>a .: OWNER
IL
BLOCK _—TRACT A D$� � - BR C
,4DESS
NO,OF BLDGS. y`
SIZE OF LOT NOW ON LOT P,�TY 1�a"-1,'' .,,J• '�,1 TEL. N
USE OF DISTRICT NO. j GROUP MAP
BUILDINGS — - _ BK PG
CONTRACTOR _ �' , �. .,,•�,-
�, CONNECTION DATA_ -
ADDRESS ` �_----
.�. 9TAT10N -.:` �
i .,4 ^' p +' DEPTH
CITY a' ..`7EL, NO. s — i —
MANHOLE R£FERENCEJ ,_ i3PFER;
.. G STATE -- ---- �' _`` = ;:" 2,�
REGISTRATION NO. - (] COUNTY
NO. 1 DESCR)PTION OF WORK FEE -- — — — —
TYPE OF CQNNECT[Otrl LENGTH FROM --,
UUSE SEWER-CONNECTING TO ! -r-- Y. GURB = P.L. M.L.TO P,L.
P7 `
PUBLIC SEWER@ s 3.50� , — --- � ----
SEPTIC TANK,SEEPAGE PIT OR
PITS AND_{OR DRAINFIELD E� $3.0OT I -- -- --
OVERFLOW SEEPAGE PIT.DRAINFIELD--- - r P. C. N0.
EXT N.,CESSPOOL,DRYWELL,MAN H0LE QP S 2.00 i CO. 1MP. .10B NO.
HOUSE SEWER CONNECTING TO i
PRIVATE DISPOSAL SYSTEM 0", S 1.00 TRUNK PERMIT NO. ROAD PERMIT NO.
CO"£GT ADDITIONAL BLDG.OR STATE ENCROACHMENT
IWORK TO HOUS E SEWER 1.00 j_ PERMIT NO.
I ALTER,REPAIR OR ABANDON HOUSE !
SEWER OR DISPOSAL,SYSTEM �, $1,00 INDUSTRIAL _
WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT 00 — --.
AUTHORIZATION � TOTAL FEE - REIMBURSEMENT FEE -
—I.t" �4
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- APPROVALS DATE INSPECTOR SSIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. NEW HOUSE SEWER I -
SIGNED THIS— - DAY OF__--.__—__. -19 CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK
OWNERS AGENT_. .--._._._.._^--_— SEPTIC TANK,SEEP. PIT($)
AND"OR DRAINFIELD.
HEREBY ACKNOWLEDGE .THAT 1 HAVE READ THIS APPLICATION -�
CESSPOOL L., DRYW ELL G
t:ND STATE THAT THE AcOVE IS CORRECT AND AGREE 70 COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR,SEWER OR I _
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM J
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR
DISCONNECT PLUG AND '
LICENSED AS REQUIRED 9Y LOS ANGELES CCL'PiT" AND STATE OF
.CALIFORNIA OR THAT 1 ANI THE LEGAL OWNER OF T14E .ABOVE ABAttiDON HOUSE SEWER i
DESCRIBED RESIDENTIAL PROPERTY. BACkFILL SEPT C TANKS
SIGNATURE "EFP. 1T;Sf i_] CESSPOOLS
OF PERMITTEE _
I
JOHN A. LAMBIE, COUNTY NGINEER VALIDATION ROBERT A. WOOD, CHIEF PLBG. INSPECTOR
4?1 5`4 5rr,:> Ie I_i: .F 5,.��.' A