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°A8S2® APPLICATION FOR PERMIT 1
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DI;Building
ISION BUILDING
ADDRESS
IOHN A. LAMBIE, County Enneer
CASSATT D. GRIFFIN, 5up't of LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL
DESCRIPTI.O_N LOT NO jOWNER
BLOCK TRACT Z."'-.' Z,.' MAIL
ADDRESS
NO.OF BLDGS.
SIZE OF LOT P40W ON LOT CITY TEL, NO.
USE OF
BUILDINGS DST
4 IGT N0. GROUPMAP PROCESSED BY
CONTRACTOR - - RK PG
--
ADDRESS CONNECTION DATA
CITY' TEL.NO, _ STATION ._t DEPTH
STATE MANHOLE REFERENCE
REGISTRATION N0. _ COUNTY LOW_ -.
NO. DESCRIPTION OF WORKFEE _
HOUSE SEWER CONNECTING TO
PUBLIC SEWER _ @ $3,00 I TYPE OF CONfFECTION LENGTH FROM-I"
SEPTIC TANK,SEEPAGE PIT OR Y. , CURB-, P.L. M.L.e'O P.L. :,
ITS AND/OR DRAINFIELD @ $3,00
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN..CESSPOOL.DRYWELL @ $2.00 _
HOUSE SEWER CONNECTING TO - P,C.NO.
PRIVATE DISPOSAL SYSTEM @ `1.00 CO.IMP,NO, /� �',� JOB NO.
G"
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT N0.
WORK'id HORSE SEWER C3 $1.00 _
ALTER,REPASR OR ABANDON HOUSE STATE ENCROACHMENT
SEWER OR Di5P0 AL 5Y57'EM @ �I.00 _PERMIT NO.
s INDUSTRIAL -WASTE APPROVAL
CHARGES
Ts OWN'ER'S PERMIT $ 2 00 'CONNECTION CHARGE.FEE
AUTHORIZATION TOTAL FEF ( REIMBURSEMENT FEE
I HAVE AT THIS DATE, A CONTRACT WITH THE HEREIN NAMED CON- _ -
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS I DATE I INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER. } ��
SIGNED THIS�v,w._.DAY ®F_-- NEW HOUSE SEWER li
OWNER OR CONNECT ADDITIONAL
OWNERS AGEtI7. ._.___._.� --_-��_._. _ BUILDING OR WORK
ADDRESS- _ SEPTIC TANK,SEEP.PITS)
-- — AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY _CESSPOOL D DRYWELL. Q
WITH ALL COUNTY ORDINANCES AND STATE, LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS, ALTER,REPAIR.
E ER OR
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR SEWAGE
EWAG DIS PLUG AND
EM
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT
ABANDON CTULE SEWER
CALIFORNIA OR THAT I AM THE LEGAL. OWNER OF THE ABOVE
DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS ❑ 7
SIGNATURE SEEP,PIT IS) ❑ CESSPOOLS ;Q _ I
OF PERMITTEE
E VALIDATION ROBERT A. i!'I/OOD
(CH. M.o. CASH SLIFERVIs1NG MECHANICAL ENGINEER
I
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