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APPLICATION FOR PERMIT ¢;
AE3 D SEWER---SEWAGE DISPOSAL �.
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINE-1F1
BUILDING AND s FETT� I5I%3ISION Bu1LDII!
I€OFYN A. LAMBIE. County Enclineer RDURESS
'YYLYAM A, Ii P75EN,Sup't o$b-ilding I,DCAL.ITY _
NEAREST - -
FOR APPLI .ANT TO FILL IN CROSS ST.
LEGAL -
DESCRIPTION LOT NO �.,rt�,�,. -�� L7 - .�".r~� i�'L' 2- ER _.�..
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BLOCK TRACT MAIL
.:;'
ADDRESS
NO.OF BL:DGS. -
SIZE OF LOT NOW ON LOT CITY" TEL. AFD.
USE OF
BUILDINGS DISTRICT NO. GROUP .f,1AP PROCESSED BY
Bid PG
CONTRACTO _ - �� „ .. 7 7 -
ADDRESS ' .•n �' "� CONNECTION DATA
CITY " - TEL1IL .ND " STATION. � �1 DEPTH
.{ K
_H
STATS: MANHOLE REFERENCE
REUISTRATiUN N0. f v � H COUNTY
NO.
_ S�RIPT( N OFWORK FEE
HOU-SE SEWER CONNECTING TO .i
Pudic s�W�� GG
TYPE 6F CONNECTION LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR Y CURL P.L. M.L.TO P.L.
PITS AND/OR DRAINFIELD $3.00 -
O4 RFLOW SEEPAGE PIT, DPAINFiELD
EXTN Ci SS?GOL.DRYINELL E.00 _
HOUSE SEWN R CONNECTING TO ;,? '1�' P.C.AFD,
PRIVATE n PGSA�SSYSTEM @ $1.00 CO, IMP, NO, JOB NO.
CONNECT ADS iONAL BLDG.6R
�tRK TO HOUSE
SEWER TRUNK PERMIT NO. ROAD PERMIT P40,
NI _ C� -
® ALTER,RE PAIR OR ABANDON HOUSE f STATE ENCROACHMENT - J'
SEWER OR DISPOSAL SYS .TE
@ $1.00 I RM37 N_0. O
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNER'S PERMIT S ��-..2_ 00 � CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE ? '/
REIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNA'T'URE
TO THE PUBLIC SEWER.
SIGNED THIS DAY OF 19- NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL (...
OWNERS AGENT -BUILDING OR WORK {
ADDRESS SEPTIC TANK,SEEP.PIT(S) -
------ AND;OR DRAINFIELD i
I 14EREBY ACKNOWLEDGE THAT. 1 HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL. ❑ DRYWELL ❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING. ALTER,REPAIR,SEWER OR
PLUMBING APF° SEWERS, - ALTER,
REPDISAIR,
S ER ORIF
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS AN LES COUNTY A STATE OF ABANDON HOUSE SEWER.
CALIFORNIA OR THAT AM � �' EGAD,DW - D _nHE ABOVE BACKFILL SEPTIC TANKS'
DESCRIBED RESIDEMALRO ,� ❑
^a16NfiTUREPIT(5) ❑ CESSPOOLSOF PERMIT'i 'f
WALI�A�'IOl�i ROBERT A. WOOD
CK.>` M,0. CASH SUPERVISING MECHANIC-AL. ENGINEER
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