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APPLICATION FOR PER IT
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER SEWER—SEWAGE DISPOSAL
BUILDING AND SAFETY DIVISION
JOHN A. LAMBIE, County Engineer ADDRESS 4i
WILLIAM A. JENSEN. Sup't of Building
LOCALITY
NEAREST—
FOR APPLICANT TO FILL IN CIR055 ST
-LEGAL
DESCRIPTION LOT NO.
BL)'L"'N G
RESS
CA L",
REST_
11 TrA
5 S 'T I,
MA�L
BL OCK TRACT
IOPRESS
NO. OF SLOGS
ON LOT CITY `7
SIZE OF LOT TEL. NO
USE OF------ ----
OJILDINGS DISTRICT NO. GROUP MAP BY
PG
R<CONTRACT 0
CONNECTION_. ATA
ADDRESS
-7�,7 Nt,y DEPTH
CITY IEL,
MANHOLE REFERENCE
RECISIRATiON NO L
-N-071--DE- N WR
CRIPTIOOF OK FEE
S -------- Y---TYPE CONNI;.�CTIOK' LENGTH FROM
HOUSE SEWER CONNECTING T 0 --7 1 - - -"
PUEIL C SEWER @ $5 CVRt O M-L.TP.L.
-
T .S�p-h TANK SEEPA�G- ------- 0
. E PIT OR 0.
PITS ANO/OR DRAINFIF-1 0 4 $100CO. .C.N0 .-IMP.NO.--- jOB NO.
I-COUSF SEWER CCINNE-CiiNG TOTRUNK PERM('{NO. ROAD PaRMITNO.
"F!VA,rE Li4spc)SAL, SYSTEM $3.00
AL1,01 TIONAL ULD—G.OI A' _DAVIT WAV k7 rA'SEMVW (DATE
I I
WORK TO HOUSE SF/NCR @ $3.00
OVER11*LOW SEEPAGE PjT-.ViRAINIL:6
FXTN CESSPOOL.DRYW ELL.MA N HOLE @ $5,00
AI.7c-R,RFPA,R OR ABANDON HOUSE HWY.OR ST.WiOFNING
�EHMII iO
NDUSTRIAL
WA5TE APPR OVAL
-----------
rEws
Om RMIT 21 00
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE
I HAVE AT THIS DATE' A CONTRACT WITH THE HEREIN NAMFLI
O CON- RMBURSEMrNTFEE
TRACTOR
DWELLING
TO THE UBLIC SEINER, APPROVAL
PT G CONNECT THE ABOVE DESCRIBED EXISTING. S DATE INSPECTOR'S SIGN.AlURL
SIGNED THIS-__-_DAY Or
OWNER OR NEW HOUSE SEWER
OWNERS AGENT-------
CONNECT (,011?ONAL
ADDRESS BUILDING OR WOR,
EREBY ACKNOWLEDGE THAT I SEPTIC fANK SEEP,PIT(5)
I
H HAVE READ THIS APPLICATION ANDIORDRAINFICL.0
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
F �,9 G AND SEWERS. -RYWF
LU IN CESSPOOL D _LL
HEREBY CERTiF 1 A-M PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICEN3ED AS RE .JIBED J9Y LOS ANGLES COUNT
D STATE OF SEWAGE DISPOSAI-SYSTEM
AL1 FORNIA 0 HAT I THE LEGAL NFR A4 DISCONNECT PLUG
A - INTEND TO
ABANDON HOUSE'EWER
ESIDE IN, T AEOV DE.SCR i E L P
----------------
SIGNATURE 41 13ACKFILL SEPT7C TANKS 0 t
SEEP P;_r,S) '0 CF.SSPOOLS
"VALIDATION ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
/CK", M.O. CASH
rE cns.; APPLICATION FOR PERMI
7EAZ42D �"`.�
ON OF COs ANGELES SEWER—SEWAGE DISPOSAL_ �
DEPDEDEPARTMENTT OF COUNTY ENGINEER
BUILDINGHNA. AND , CountyAFETY DIVIEngin or A
DDRPUILESS �
JOHN Aa LF►M:�TE, County Engin or REss =� �"
WILLIAM A. JENSEN, Supt of �uaikling -
LITY �s
q7�} iE57rSOT NO �tlSS 4Tr• � _ C C;
FOR APPLICANT TO FILL
L'E5C7^I TION � ? - '� , ,3�,^rNE.R
Y
hi AIL
BLD r TRACT aDr.,;zLsS y�+ �
-- ✓
SIZE OF LOT NOW
6NLOTTY S TEC NO.
USE OF
_
Bi/ILC!N6S DISTRICT NO. GROUP MAP PG PROCESSE9 BY
BK
CONTRACTOR
- - ' � - CONNECTION D,
,ADOF.ESS -- yam- _ �y� '9.,_.
CI7Y ( � D-`PTHAT
+� TEL.._ f 1 f u
REGISTRATION NO, � J )ATE MANHOLE REFERENCE
NO C3 E_SCR!PT!ON OF WORK FEE Tp OF',
,ON NSG°('N 'LEN THP M
HOUSES WER CONNECTING TO - - 1 :' =E' Q ,+�'[. M.L.TO P.t;:
PUBi IC SEWER (S�
b3.00 P.:C.NO.
TANK.SEEPAGE PIT !?£t
1_- CO.IMP.NO. J06 NO.
sio:00
P17=AND/OR r:RAINFEELD Q -__. _�
H 1USL-SEWER C: 'NNE '.NG TS'3yy
TRUNK Pi_RIW 'J IT O. ROAD.PERMIT NO }
f�
Pf t AT£DI POSAL SY r._t�y � $3.00 I � � '� �j �
COI 1E A D.T'IJNA L
BDL OR -`-_-- :OFF'i.DA✓(T 'NAIVVP EAs£MENt RErORP.IN TR.NO. DATE
WORK ro HCJSE SEWER @ SS.00
JV RF'L W SEEPAGE FiT:.DRAINFIKLD
LXTN..- S.PCOx.ORVWELL MA JHOL ;W
4.0�
- - "---' ,-- "- - J -- Hd4 Y. OP S7.4YInEN NG
Air n,RFPAiR D G,NDON HC. SE !
SEW E2'7R')5F A Tt �/I ---
_.__ -_ _ _ STATE EN ROA HIAENT
R RNIIT NO.
------ -.__s�.�' � ..__-_. 1NDiiSTR.IAt -
�, WANE APPROVAL
ARGES
OWNER'SPERMIT coeJNFr oN'
CHARGE PEE
AUTHORIZATION TOTAL FEE --- -- ----- ------ -- -----
I STAT THIS DATE A CONTRACT WITH 'TETE HEREIN NAMED CON. REIMBURSEMENT FEE --
! AVEf RA„TOR T"i ONNECT THEABOVE DES,,RIBF_D "!STING DWELLING
TO THE PU EUSEWER.G C SEWER. APPROVALS DATE , IN&P F.0 TOR 5 SIGNATURE
SIGNED THIS...,---DAY OF -' ------�.9J ---- ----'--__-.._- _-- ____-_. ---'-----
OWNER OR poll NEW HOUSE SEWER �
OWNERS AGENT_.. Cr NNECTADDITIONAL_ .--
HUILOIR'+IC GWORK
..,ACC?fi£.S.__
r
SE TIC.TANK.sF_tR,PIT(5) �
{EREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND i O F DR A I NF f E'.D
AN.^ .TATE:' THAT T14E ABOVE: IS CORRECT AND AGREE TO COMPLY
WITH. ALL COUNTY ORDNANCES AND STATE LAWS REGULATING
FLUMBING A CESSPOOL F—O ] _. i I
r'/ T IMAM PROPERLY RE-GISTERED AND/OR ALTER REPAIR,SEWER R ---------�--- _--_----
NL SEWERS a CRYW:LL i
i HERE B'7 f'ERiI, AT �
L{CFN SED A1- REUi4 F'D B'i�+'+L O5 ANGLES UNTY AND STATE OF SEWAGE DISPOSAL SYSTEM I
C'A.L:F ORN1.7 6R A'! AMI(HE. LEGAL R OF' AND ANTEND TO L1ISCONNE.:T !=LUG AND
C
RESIDE IN, TH ABOVE G.CRIBED RF EN I.A ROP-RTY' ABANDON HOUSE SEWER
OF PERW TE BACKFIL..L SE'PT'IC TANKS [;7
__ _L SEEP,PIT(Sy CESSPOOLS Qi
VALIDATION ROBERT A. WOOD
,'C K. M.-0. CASH SUPERVISING MECHANICAL ENGINEER
-'