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76AS-'t2Q APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BU L.D IN
JOHN A, LAMBIE, County Engineer ADDRESS.�-=-
WILLIAM A. JENSEN, Supt of $ ilding r
LOCALITY
NEAR ES7 ,'_
FOR APPLICANT TO FILL IN RCSB ST - -
W LSCMI PTiOTv _0T NO a OWNER C' `
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BUiLJ T GS ' i-j _" DISTRICT NO, GRCUP MAP FR 0C.C SSED BY
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CONTRACT
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A 0 D R E Ss s CONNECTION DATA
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CITY STATION f DEPTH .
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STATE
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REG'ST'AT,ON N'0. COUNTY MANHOLE REFERENCE ] LOWER
-- = = ---- -� ----�----- _ r
NO. DESCRIPY'ION OF _0RK FEE
TYPE O ON NECTCON LENGTH rRCIM
YHOUSF SEWER GON NEST YN(s TO --, Y.. i cu Rri P.T_' M.[: TOP L J C,
P178 IC SEWER @ $5.00 r- --_ _ ____ _— ._-_.
_- _�_ -_-.__ ___-..__ P C NO3
Sf P.-iC:TAN K.FEEF;AGE PIT OR :,:_¢.j ., ..
PITS AND OR DRA.INFII'LD @ $10.00 O.IMP NO _.�_� ._ JOB NO.
HOti.E SEWER CONNECT INC TO 'T'RUNK PERM;T" NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM $3.00 +..
-
C)NhEC'ADDITIONAL 6LDC OE. AFFIDAVIT I WAIVER T EASEMENT RECORD INSTR.NO.� DRTE
WORK TO HOUSE SEWER @ $3.00 1
OVERFLOW SEEPAGE .7. D.RhiNr1ELU
EXI N.,CESSPOOL,DRYWELL.F ANHOLE` $5.00
i -___ HW!'.OR S'T.WIDENING ALTER.REPAIR AIR OR ABANDON HOUSE
' -
s
SEWER OR C.SP CSAL SYSTEM $3.00 : STATE EFFG ROA CtiMENT -
i
-- - PERMIT NO.
INDUSTRIAL
I WASTE APPROVAL
CHARGES
OWNER'S PERMIT � z! 90 -- --- --- — ---- -- - ----
AUTHO7 gip% py --------- ------
RIZATION TOTAL FEE 91 CONNECTION CHARGE FEE
1HAVE AT THSS DATE A CONTRACT WITH THE. HEREIN. NAMED CON- IRE
TRACTOR TO CNE,.T THABOVEDESCRIBED EYISTiNF DWELLING
IM5U R5EM ENT FETE
_ :E . ' �
q�e
TO ?'nE , J@� C SEWER: APPROVALS DATE INSPECTOR...SIGNATURE
slcNEa THrs ----�day oF.�� —----'a—_ I —y--------
r_.. l,:' »'I NEW HOU E SEWER
OWNERS AGENT -
.- CONNECT ADDITIONAL
_BUILDING OR WORK
AD RESS.____ 111
SEPTIC TANK,SEEP PiT(5) _..�
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION AND,'OR DRAINFIFLD
STATE" THAT THE ABOVE. i5 CORRECT AND AGREE TO COMPLY
WI-4 AL' COUNTY ORDINANCES AND STATE LAWS REGULATING T
PLUMBING AND SEW F-R$.
CESSPOOL _JDRYWELL ❑ '
I' HEREBY CERTIFY THAT i AM PROPERLY REGISTERED AND:OR ALTER,REPAIR.SEWER OR I
L.I CENSEO AS REQUIRED BY L05 ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM, �
ALN;A OR FH AT 7 AM TFiE
LEG OWNER OF, AND INTEND 70 - —"-- -----'---"-----_" -
DISCONNECT PLUG AND
R .. i DfNT
ABANDON HOUSE INTHE ABOVV,DESCR!BED REST _ SEWER
SIGNATURE
-- -.- __
OF PLii I+9:TTEE ✓ - - BACKFILL 5 DTIC TANKS
SEEP,P.7.S) L CESSPOOLS [�li
VALIDATION ROBERT A. WOOD
CK. M.O. •CA.SP. SUPERVISING MECHANICAL ENGINEER