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76a 8420 APPLICATION FOR PERMIT
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
LOCALITY �___
FOR APPLI TO L IN CROSSSST.
LEGAL
DESCRIPTION LOT NO. �, ..,-� OWNER x1
MAIL
BLOC RTRACT (c ADDRESSa-
NO. OF BLDGS.
512E OF LOT T
_ ') NOW ON LOT P CITY ., TEL. NO. 7y
USE OF
BUILDINGS71:)
' . r' 1 /a.` - DISTRICT NO. GROUP MAP OESSED BY
BM PG ,
CONTRACTOR
ADDRESS o/514-- CONNECTION DATA a _
CITY - / C' TEL. NO. r f. STATION �ir DEPTH �..,.s
STATE LIC MANHOLE REFERENCE / UPPER+7
LICENSE NO: CLASS 41-
44- Li WER
NO. DESCRIPTION OF WORK FEE `"----'--- -------- —
TYPE OF COECTION LENGTH FROM
J HOUSE'SEWER CONNECTING TO Y. //CE7R$•,— -P.L M.L.TO P.L.
J PUBLIC SEWER $5.00 -'y! 1 c
SEPTIC TANK,3—EPAGE PIT OR -- 'y P.C.NO.
PITS AND!OR DRAINFIELD CO.IMP.NO. ,9 .- JOB NO.-
_.T_.__—_ —____.. _ SIO:00 _
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM $3.00 'I:?UNK PERMIT NO. ROAD PERMIT NO.
vt_-_--_.__-
i CONNECT ADDITIONAL BLDG OR ��- gFFIDAV ITFWA�VIRJI�Alll*INTRECORD. INSTR.NO. DATEWORK.TO HOUSE SEWER @ $3.00OVERFLOW SEEPAGE PIT,DRAINFIELD O
EXTN.,CESSPOOL.ORYWELL,MANHOLE 0 $5.00
e_-_ -.__ ___ _
ALTER,.REPAIR OR ABANDON HOUSE ---I. ��---- HWY.OR ST.WIDENING V
OR DISPOSAL SYSTEM $3.00 1 ------------- --- -- w
-SEWER -D -_-$3:0 t--- STATE ENCROACHMENT D-
PERMIT NO. C/)
--------"---- -- INDUSTRIAL
WASTE APPROVAL
�^ -------- CHARGES
OWNER'S PERMIT -_---s i z! oo -- --- -----
AUTHORIZATION TOTAL FEE / CONNECTION CHARGE FEE �- -- —
I HAVE AT THIS DATE A CONTRACT WITH THEHEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO-CONNECT THE ABOVE DESCRIBED 17 STING DWELLING
TO THE PUBLIC SEW R. APPROVALS DATE IN CT0 SI qTU RE
SIGNED THIS� Y OF� Ig�yi�y --- -
OWNER OR i:'"'""� -T NEW HOUSE SEWER 7 of
OWNERS AGEN- rr CONNECT ADDITIONAL '— — --
BUILDING OR WORK
ADDRESS _
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATtON� SEPTTANK.SEEP,PIT(3)
AND STATE.THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY AND/O/R dRAINFIELD
WITH ALL COUNTY ORDiNANOES AND S'IA7E LAWS REGULATING
PLU MBI NG AND SEWERS. CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR.SEWER OR
CE
LINSED AS RE"
BY LOS ANGLES COUNT,, AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR T I A THE yEGAL O ER AND INTEND TO DISCONNECT PLUG AND
RESIDE SN, THE A VE S-H D REST TIA 'PROPERTY. ABANDON HOUSE SEWER
SIGNATURE ' - --- - -.--
Of PERMITTEE_;j,_� � _.'s-�' '"`'' s��_ BE,.0 KFILL SEPTIC TANKS ❑
SEEP,PIT(5) ElCESSPOOL5 7®-__
LM TION JAG R. ALLEN
cK. M.o. CASH SUPERVISING MECHANICAL ENGINEER