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APPLICATION FOR PERWIT
COUNTY OF LOS ANGELES SEWER—"SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS
IOFIN A. LAMBIE, County En inaer
WILLIAM A. JENSEN, Supt 0t Building LOCALITY
NEAREST �-
FOR APPLICANT TO FILL INf__c_R_OSS ST, r
LEGAL
DESCRIPTION LOT ND ' ':% Ki a� t �'"• OWNER 99 .
BLOCK TRACT .'� MAIL
ADDRESS
/ NO.OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO. _
USE OF
BUILDINGS DISTRICT NO.. GROUP _ MAP PROCESSED BY
r BK PG
CONTRACTO � ,:. r r t K
R. y
ADDRESS 3 J. CONNECTION DATA r
CITY '7
STATION 1 DEPTH
�,FATE MANHOLE REFERENCE (z"
REGISTRATION N0. 'L ° � - Q COUNTY ~ �s LOWER `
NO. DEKRIPTION OF WORK- FEE �,-
-=•i HOUSE 5E NF-R CONNECTING TO _ �".. A
I PUBLIC SEWER Cu $3_00 TYP+ OF CONNFtTpN LENGTH FROM �.: "" /Y
�SEPTIC TANK.SEEPAGE PIT OR Y. CURB I P.L.- M.L.TO P.L. t
PIT$AND/OR DRAINFIELD @ $3.00 —^---R+ -
I OVERFLOW SEEPAGE PIT, DRAINFIELD
I EXTN..CESSPOOL..DRYWELL @ $2.00
HOUSE SEWER CONNECTING TO =/ „� '-� P.C.NO.
_. PRIVATE DISPOSAL SYSTEM SI.00 CO.IMP. NO, r''a JOB N0. },
CONNECT ADDITIONAL BLDG.OR •'S -' L'"
HOUSE SEWER @ ,GO TRUNK PERMIT NO. ROAD PERMIT N0. OU
WORK TO -.�
ALTER.REPAIR OR ABANDON HOUSESTATE ENCROACHMENT
SEWER OR DISPOSAL SYSTEM C� $1.00
PERMIT N0, Q
( —PERMIT
-
WASTE APPROVAL
P.
CHARGES
OWNERS PERMIT s 2.1 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE t,t I ' REIMBURSEMENT FEE
CON-
TRACTOR TO CIONNECT THE ABOVE DESCRIBED EXDATE A CONTRACT WITH THE IISTINGEINAMED DWELLING . APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS DAY OF 19— NEW HOUSE SEWEROWNER OR i
OWNERS AGENT CONNECT ADDITIONAL
_BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP. T
PIS)
AND/OR DR.AINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION _
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL 0 DRYWELL
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. PAIR,ALTER,RESEWER OR
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED. AND/OR SEWAGE REPAIR,
S SYSTEM
DISCONNECT PLUG AND e
LICENSED AS REQUIRED BY LOS A ''ELES COUNTY AND-$TATE OF _ABANDON HOUSE SEWER
CALIFORNIA OR TK" -j.A � THFi'LEG L OW:N OF T14E .ABOVE —
DESCWBED R£SIDr TIAL; Y.
�1 < r' I3kCKF(LL SEPTIC TANKS [f
-� SEEP,PIT(Sj I CESSPOOLS ❑
SIGNATURE . .-f
OF PERMITTE
�< 'VALIDATION ROBERT A. WOOD
eK. M.o, CASH SUPERVISING MECHANICAL ENGINEER;