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6.53 APPLICATION FOR P RIMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING .--
JOHN A. LAME, County Engineer ADDRESS _
CASSATT D. GRIFFIN, Supt of Building LOCALITY
NEAREST` ~....
FOR APPLICANT TO FILL IN rC.R.055LEAL
DESCRIPTION LOT NO4_ � OWNER
BLOCK TRACT 2 / MAIL
_ = f.' ADDRESS
NO OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF -1
BUILDINGS DISTRICT N0. GROUP MAP PROCES_ED BY
i BIC PG !
CONTRACX
`_ .- ( g EEE
ADDRESS r '!; t-' .: ;^ ,. _ CO 14LGAION DATA "
CITY 1 s TEL.NO. 5 Ca"
- �,-.;'_ �� I� -_� , ,ON r=� ✓��„„ DEPTH
STATE MANHOLE REFERENCE .-'l % Y y y
REGISTRATION N0. .,. -Y ,✓ �-,- --�- COUNTY f� � t o,/ ,k,• OWEf2
NO. DESCRI€'TION OF WORK FEE —
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3.00 TYPE OF CJNNEG"e'ION LENGTH FROM�T J
SEPTIC TANK.SEEPAGE PIT OR Y. CURB P.L. 11..L.TO P,L.
PITS AND/OR DRAiNFIELD $3,00 , _ -
OVERFLOW SEEPAGE PIT,DRAINFdELD I _..,9�e a
EXTN.,CESSPOOL. DRYWELL @ $2.00 t
HOUSE SEWER CONNECTING TOP.C ND.
PRIVATE DISPOSAL SYSTEM @ $1.00 _CO. IMP.NO, ;� .•`� '� JOB NO,
CONNECT ADDITIONAL BLDG.OR TRUNKPERMITNO. ROAD PERMIT NO. I r
WORK TO HOUSE SE:VIER @ $1.00 _ �/. k�'
ALTER,REPAIR OR ABANDON HOUSE STATE E NCR.OACHMENT
i -EWER OR DISPOSAL SYSTEM @ $1.00 PERMIT NO,
WASEAPPR
WASTE APPROVAL
_ CHARGES
OvmR`aS PERMIT $ 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE � � REIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE 14ER.F.IN NAMED CON.
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE I INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS DAX OF 18® NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP,PIT(S)
_AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT Aldo AGREE TQ COMPLY CESSPOOL _❑ 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 ABANDON HOUSE SEI"EER
CALIFORNIA OR THAT 1 AM THE LEGAL 0 OF TPtE ABOVE
DESCRIBED RESIDErNAL PRO RTY, g BACKFILL SEPTIC TANKS ❑
SIGNATURE ,t rr - 'r---` SEE�(S) 11CESSPOOLS
OF PERMITTE y✓. ` I "+'
>� VALIDATION ROBERT A. WOOD
CK M.0. CASH SUPERVISING MECHANICAL ENGINEER.
APPLICATION FOR P RMIT
'BA042D t T
E808 8-59 S
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING ANI? SAFETY DIVISION 7NEE1,R'EST
ING
JOHN IL LAMBIE, County E inesr SS _ `, ✓ x_ s -
m4
CASSATT D. GRFFFIN, Supt ofuitdiaq iFOR APPLICANT TO FILL IN ST.:4�
LEGAL
DESCRIPTION LOT NO. OWNER
BLOCK TRACF�vr. MAIL
__ {.s•� r a: ADDRESS
NO.OF'BLDGS.
SITE OF LOT NOW ON LOT CITY TEL. NO,
USE OF
B.UILDiNGS r �- ---- DISTRICT NO. GROUP MAP PRACE�SSE.DBY
,,� BK PCs
COPiTRACTO 44 A - l ; f
ADDRESS
CONNECTION DATA
11 ,
TEL.NO. " ?� ION 19 DEPTH
REGISTRATION N0. i _�. STA E MANHOLE REFERENCE
COUNTY 1 w y r L WER
NO. DESCfiIPTION OF WORK FEE
HO LIGE SEWER CONNECTING TO
PUBLIC SEWER @ $3.00 j TYPE OF CONNECTION LENGTH FROM 77-7
Y
SEPTIC TANK,SEEPAGE PIT OR Y. CURB P.L. �. M.L.TO P.L, � y
PITS AND/OR DRAINFIELD
.OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN..CESSPOOL,DRYWELL @ $2.00
HOUSE SEWER CONNECTING TOP.C.NO.
P PRIVATE DISPOSAL SYSTEM $1.00 _CO.IMP. NO. p�' ?T ems;; '1 JOB NO.
CONNECT ADDITIONAL BLDG,OR i
WORK TO HOUSE SEWER @ $1.00 TRUNK PERMIT N0. ROAD PERMIT NO. fI Y w
ALTER,REPAIR OR ABANDON HOUSE STATE ENCROACHMENTSE. ER OR DISPOSAL YSTENI $1.00 PERMIT N0.
INDUSTRIAL
WASTE APPROVAL
LL" v - CHARGES
OWNER'S PERMIT $ 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 I GATE INSPECTOR'S SIGNATURE
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
1 HERESY ACKNOWLEDGE THAT 1HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORR.ECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL ❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL.SYSTEM
I HEREBY CERTIFY THAT 1 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 OWN} OF THE ABOVE
DESCRIBED RESID "-AL PROP0TY -_._ BACKFILL SEPTIC TANKS ❑
+ -� 5 P.PIT(S 0 CESSPOOLS
SIGNATURE: 1
7
OF' PERMI7TE �" �`•" _ �", '�.-t s
le VALIDATION ROBEiRT"A. WOOD
cK. :' X.0. CASH SUPERVISING MECHANICAL, ENGINEER
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