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241160 INSERTS
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76AC1420 APPLICATION FOR PERMIT/
COUNTY OF LOS ANGELES SEWER SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION A9,U��
WILLIAM
A IE un En ineer
SF
,kFo
S.P�y
ILL11M_41MEN t of Cidiq LO e
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL
DESCRIPTION LOT NO. OWNER
BLOCK TRACT MAIL
ADDRE
NO.OF BLDGS,
SIZff OF LOT,.'L ON LOT NOW CITY'' TEL. NO.
USE OF
_HJD Lt�G_s DISTRICT NO. GROUP MAP PROCESSED BY
BK P6
CONTRACTOR 4
ADDRESS CONNECTION DATA
CITY, �Z!2��EL .NO. STATION -4, DEPTH
STATE MANHOLE REFERENCE UPPER"I
4,
G_ISTRATION NO. COUNTY
No. j DESCRIPTION OF WORK FEE
'OUSE SEWER CONNECTING TO -
PUBLIC SEWER C--$--'00 L-_::� c TYPE OF CON NECTIOty�_,#4,,,,,, LENGTH FROM
SEPTIC TANK.SEEPAGE PIT OR Y. CURB1
ITS AND/OR DRAINFIELD @ S3.00 P.L.P.L. M.L.TO P.L.P�
OVERFLQ4 'EEP-JFIT. DRAINIIELD
E�',N "�;Sn'AGE YDRYWELL @ $2.00
110�3SE EWER CONNECTING TO. P.C.NO.
P VATI'DISPOSAL SYSTEM @ $1.00 _-O. IMP. NO. r JOB NO, a.
CONNECT ADD]rlONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT NO. 0
WORK TO HOUSE SEWER $1.00 U
ALTER, REPA:R OR ABANDON HOUSE STATE ENCROACHMENT ig
�OSAL SYSTEM
$1.00
5EWER OR DIS PERNJT NO. 0
WASTE APPROVAL
CHARGES LQ
OWNER'S PERMIT 1 2 00 CONNECTION CHARGE FEE
V
AUTHORIZATION TOTAL FEE6 I 4C,IE REIMBURSEMENT FEE 1 i
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN Am CON-
TRACTOR TO CONNECT THE ABOVE--DESCRIBED EXIST14G DWELLING APPROVALS DATE INSPECTOR*S SIGNATURE
TO THE PUBLIC SEWER.... 7-
SIGNED THIS y OF` 19 NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERSAG BUILDING OR WORK
SEPTIC TANK,SEEP.PIT(5)
ADDRESS_45K AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPL,146ATION
E
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL El DRYWELL Cl
WITH
ITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I ER
HE R,HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT AND
LICENSED AS REQUIRED 13Y LOS ANGELES COUNTY AND STATE OF ABANDON,HOUSE SEWER
L I R.IA
CALIFORNIA OR THAT I AN THE LEGAL,OWNER OF THE A13OVE
C I R B.ACKFJ LI,SEPTI C T=,O
LDESCRIBE ESIDENTIAL PROPERTY.
E
C
.5 ,AT U V SEEP.PIT(S) ED L, L
SIGNATURE
0 F P C R,I T
OF PERMITTEE
VALIDATION,—`, ROBERT A. WOOD
CK. U.0, sH r SUPERVISING MECHANICAL ENGINEER
9-4
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