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:A64 3-61 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL `
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION ADDRESS
JOHN A. LAMBI£, County Engineer
ADDRESS
WILLIAM A. JENSEN. Sup't of Building
_ LOCALITY
NEAREST
FOR APPLI'OAM TO FILA. IN cRDss ST.
DESCRIPTION LOT N0. `— OWNER 12,
BLOCK TRACT MAIL _
5
ADDRESS /,I j
NO.OF SLOGS. ,
SIZE OF LO& .NOW ON LOT CITY L. N0.
USE OF DIST ICT N GROUP MAP PROCE 43Y
BUILDINGS
BI[ P6 'r
CONTRACTOR. i l
--
ADDRESS >� °: CONNECTION DATA
LL_
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.TEL.NO. .A�-,. STATION » � i-� � DEPTH
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`ar
y STATE MANHOLE REFERENCE c Ir' PPER
REGISTRATION N0, 2 COUNTY
N0. I DESCRIPTI0N OF FEE
PRL YERONNECTING TO $3,00
TYPE OF CONNECTION
SEWER
LENGTH FROM
SEPTIC TANK,SEEPAGE;PIT OR YZ CURB P.L. M.L.TO P.L. -
PITS AND/OR DRAINFIELD @ $3,00
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN..CESSPOOL.DRYWELL $2.00 _ 0
HOUSE SEWER CONNECTING TO J ---- p
C.NO.
PRIVATE DISPOSAL SYSTEM @ $1-.00 CO.IMP. NO,. JOB NO. (.J
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT NOV(^
WORK TO HOUSE SEWER $1.00 _
SEWCR OR D41SPOS L SYSTEM HOUSE $1.00 STATE ENCROACHMENT
PERMIT N0, U U
w
INDUSTRIAL
WASTE APPROVAL
CHARGES
Oit17 WS PERMIT $. 2 00 CONNECTION CHARGE FEE
AUTH013 ATIONT TOTAL FEE 97' REIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SNGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS DAY 0 NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL -
IITCENSED
NERSAGENTBUILDING OR WORK
DRESS SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELDHEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
D STATE THAT THE ABOVE #S. CORRECT AND AGREE TO COMPLY CESSPOOL DRYWELLTH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
UMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
AS REQUIRED =BY LOS GELES COUNTY AND S ATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT AM TH -�1.EG 0 N TH ABOVE BACKFILL SEPTIC TANKS [,
DESCRIBED RESID�NTI ISROPER ,
DESCRTU'RE -� SEEP.PIT(S" GJ CESSPOOLS
SIGNAOF PERMITI
VALIDATION(-' ROBERT A. WOOD
CK. U.0. i' CASH SUPERVISING MECHANICAL,ENGINEER