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78A8420 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUMDING AND SAFETY DIVISION BUILDING �+d7/dor �� Q✓G
OHri A LAMBIS CoBIIty Eny1n SS>! ADDRESS
A YEN= Supt of Su11d1IsQ / G+�
LOCALITY TG/7J SIG
FOR APPLICANT TO FILL 1N NEAREsr yVdjg �"
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DEBCRIGPTION LOT NO OWNERMAIL
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BLOCK TRACT 6�� ADDRESS �!O/d OQ� o✓C
NO OF SLOGS �7 EL NO
812E OF LOT NOW ON LOT CITY
USE OF J �• �+� DISTRICT NO GROUP MAP PROCESSED BY
BUILDINGS P�/O�/9 CQ AO/5•�=/� .�8 BK PO
CONTRACTOR Q.¢��/^�Q��Lm Q /i
ADDRESS /3 O•��.ICi`'C ®O,.e' �ivG CONNECTION DATA
CITY loof-41:111 .4p-*'fqg TEL NO.44w—/� - STATION 9 DEPTH
REGISTRATION NO Ile�414.t� G.^-4�jZ COUNTY MANHOLE REFERENCE UPPER
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NO DESCRIPTION OF WORK FEE TYPE OF CU B ON LENGTH FROM
IHOUSE SEWER CONNECTING TO Y PL ML TO P L
PUBLIC SEWER O SB oo -.6 OO
BEFTIC TANK SEEPAGE PIT OR P C NO
PITS AND/OR DRAINPIELD 0 $1000 CO IMP NO oe.1 z CL JOB NO 8
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO /.✓
PRIVATE DISPOSAL SYSTEM (@ 8300 ✓ 09
CONNECT ADDITIONAL BLDG OR AFFIDAVIT NMYf■ �11>fiRIMT RECORD INBTR NO DATE O
E
WORK TO HOUSE SWER ® 8800 0Q IVrY
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL MANHOLE® $500 HWY OR BY WIDENING
ALTER REPAIR OR ABANDON HOUSE Z
SEWER OR DISPOSAL SYSTEM $300 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
`:��p WASTE APPROVAL
O n1,�+E1 s PERMIT 21 OO CHARGES
AUTHORIZATION TOTAL FEE CONNECTION CHARGE PEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT PEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING R*
TO THE PUBLIC SEWER w/ �I OVA S DATE INSPECTOR B BION RE
SIGNED THIS D Y 'I7
OWNER OR NEW HOUSE SEWER
OWNERS AGENT ` ,.fir/'
ADDRESS 60/� ®OT �II�j / �+ CONNECT ADDITIONAL
BUILDING OR WORK
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION SEPTIC TANK SEEP PITIB)
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY AND/OR ORAINFI6LD
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
1 HEREBY CERTIFY THAT I AM PROPERLY RE018TERED AND/OR ALTER REPAIR SEWER OR
LICENSED AS REQUIRED BY LOB ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT AM THE LBOAL WNER OF AND INTEND TO DISCONNECT PLUG AND
RESIDE IN
THE
AB DESCRIBED 8 PROPERTY ABANDON HOUSE SEWER
SIGNATURE BACKPIL16 fEPTIC TANKS ❑
OF PERMITTEE BEEP PIT 1S) ❑ CESSPOOL
VKMMATION Roes r A wooDM O CASH SUPERVISING MECHANICAL ENGINEER
(, 5 2 2 9 w%R 4 91 0 D 1000-
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