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E806 8•59 APPLICATION FOR PERMIT -
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION auiiDlNc
ADDRESS
JOHN A. LAMBIE, County Enqineer
CASSATT D. GRIFFIN, Supt of Building LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL
DESCRIPTION LOT NO. "V OWNER ,
BLOCK TRACT MAIL
_ ADDRESS
NO.OF BLDGS.
SIZE OF LOT NOW ON LOT -- - - - CITY TEL. N0,
USE OF
BUILDINGS DISTRICT NO GROUP_ MAP PROCESSED BY
B[_C_ PG
CONTRACTOR '
J�„t
ADDRESS CONNECTION DATA
CITY _ TEL.N0, W STATION - /DEPTH 1 „r-
STATE MANHOLE REFERENCE UPPER
REGISTRATION NO. ❑ COUNTY LOWER
NO. DESCRIPTION OF WORK FEE
r HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3.00 TYPE OF COX1_+kCTION LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR - Y. CURB';. P.L. M.L.TO P.L. - <
FITS AND/OR DRAINFIELD @ $3,00
OVERFLOW SEEPAGE PIT, DRAINFIELD --
EXTN..CESSPOOL.DRYWELL @ $2.00
HOUSE SEWER CONNECTING TO - P.C.NO.
PRIVATE DISPOSAL Sy
TEM @ $1.00 CO.IMP. NO. JOB NO.
CONNECTi LONA ',BLDG�DR
WORK TO..H SEWER_ r `�- @ "$t.00 TRUNK PERMIT N0, ROAD PERMIT NO
ALTER,REPAIR OR ABANDON HOUSE STATE ENCROACHMENT "
SEWER OR DISPOSAL SYSTEM @ $1.00 PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNER'S PERMIT 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE- DESCRIBED EXISTING DWELLING APPROVALS DATE fNSPECTOR'SSIGNATURE
TO THE PUBLIC SEWER,:
SIGNED THIS ,. � DAY. OF..` 15 NEW HOUSE SEWER _
OWNER OR CONNECT ADDITIONAL
OWNERSAGENT _ BUILDING OR WORK
ADDRESS. SEPTIC TANK,SEEP.PIT(5)
-- - AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE 1S CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL ❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. ALTER,REPAIR,SEWER OR
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 ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED-RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS ❑
SIGNATURE SEEP.PIT(S) ❑ CESSPOOLS
OF PERMITTE
.^` ALIDATIO ROBERT A. WOOD
'CL H.0. CASH :' SUPERVISING MECHANICAL ENGINEER