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A542DBI APPLICATION FOR P RMIT 4...
COUNTY OF LOS ANGELES SEWER--SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A, LAMBIE, Court En ineex ADDRESS
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WILLIAM A. JENSEN, Sup'k of wilding LOCALITY
NEAREST
FOR APPLICANT TO FILL Di _
DESCRIPTION LDT NO. ! CROSS ST. _
LEGAL
p� OWNER
BLOCK TRACT J MAIL r
y ' r ,; - ADDRESS J� e 9
140.OF BLDGS. n
SIZE OF LOT NOW ON LOT CITY NO f
USE OF
BUILDINGS r DISTRICT N0. GROU> AP PROCESSED BY
r r'' BK PG
CONTRACTOR
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ADDRESS � ✓ i CONNECTIO14 DATA
CITY rj TE � e ' ❑ STATION !� } DEPTHSTATE
4
REGISTRATION NO,/ ❑ COUNTY MANHOLE REFERENCE LOWER
4,
NO. I DESCRIPTION70F WORW ff FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $9.00 7' �`'`
TYPE OF_CO#tiECTION LENGTH FROM p �.
SEPTIC TANK,SEEPAGE PIT OR Y. =CURB P.L.
PITS AND/OR DRAINFIELD @ $3.00 �
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN.,CESSPOOL,DRYWELL $2.00 4
HOUSE SEWER CONNECTING TO -J �✓��' P,C.NO. O
PRIVATE DISPOSAL SYSTEM @ $1,00 CO. IMP. NO. �' ' JOB NO. U
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT NO.
WORK TO HOUSE SEWER @ $1.00 �-
ALTER,REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
SE WER OR DISPOSAL SYSTEM < $1.00 PERMIT NO. V
INDUSTRIAL D.!
WASTE APPROVAL n
H
���
CHARGES z
�T.NOWMR'S PMWT $ 2 00 CONNECTION CHARGE PEE -
AMOP ZATION I TOTAL FEE > L REIMBURSEMENT FEE
IHAVE AT THIS DATE A CONTRACT WITM THE CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTIINGAMED DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS ��DAY 01 99� NEW HOUSE SEWER
OWNER OR Z �� $.yr,,„_.q-'._.yid..• CONNECT ADDITIONAL
OWNERS AGENT -- BUILDING OR WORK
t. _ SEPTIC TANK,SEEP.PIT S
ADDRESS t ` SEPT
ANK,S IEP, I I
I H
HEREBY AC OWLEDGE THAT I HAVE READ THIS APPLICATI ;N
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMP Y CESSPOOL.0 DRYWELL
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ARAN
60N HOUSE SEWER
CALIFORNIA OR THAT I AM THE LEGA@iIVNEll OF T ABOVE
DESCRIBED RESiDENTI BACKFILL SEPTIC TANKS
/ PERJ,,.
SIGNATURE �,�."f f :f SEEP.PIT Is ❑ CESSPOOLS
OF PER •MITTE < < -
VAMATION ROB5RT A. WOOD
CK. M.0. CASH SUPERVISING MECHANICAL ENGINEER
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