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76808E-80
76A6420 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER--SEWAGE DISPOSAL 1
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION ADDRRESS . . oz++ r
OfiN A, LAMBIE, County Engineer
WILLI M A. JENSEN. Sup't of Building LOCALITY 6 ✓
NEAREST
FOR APPLICANT TO FILL CROSS ST.
LEGAL _
DESCRIPTION LOT NO..�.
OWNER S +rl /�`'`. c ,I%
BLOCK '`'' `IBkC•t' MAIL s"
ADDRESS 4...� .. -�
NO:OFA BLDG".
SIZE OF LOT NOW ON LOT CITY TEL, NO.
USE OF DISTRICT
BUILDINGS K N0. GROUP MAP PG PROCESSED BY
_ 4
B
CONTRACTOR ' r�
c.'
ADDRESS >, CONNECTION DATA -
CITY�' ..,.tyW TEL.NO. e; STATION DEPTH '
STATE MANHOLE REFERENCE UPPER
REGISTRATION NO. ❑ COUNTY
No. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @-) $3.00 _ - TYPE OF CONNECTION LENGTH FROM
SEPTIC TANK SEEPAGE PIT OR 'Y. CURB P.L. M.L.TO P.L. -
PITS AND/OR DRAINFIELD @ $t 00
OVERFLOW SEEPAGE PIT DRAINFIELD
EX"tN.•CFSSPOOL DRYWELL @ S2,00
110113E SLVVE.II CONNECTING TO P.C.NO. -
PR'
'NATE f1tSPO'AL SYSTEM @ $100 CO. IMP. NO. JOB N0,
i^ CONNECT ADUIT:ONAL BLDG.OR 'TRUNK PERMIT NO. ROAD PERMIT NO. c �. ,f U
WORK TO HOUSE SEWER @ S�00
ALTER, REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
SEWER OR DISPOSAL,SYSTEM -;Too I PERMIT N0, O
I INDUSTRIAL E•'
WASTE APPROVAL W
CHARGES rn
OWNER'S PERMIT s 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 I INSPECTOR'S SIGNATURE
TO THE PUBLIC S` R.
SIGNED THIS DAY.PFS 1 _ NEW MOUSE SEWER
OWNER OR �_ _ J CONNECT ADDITIONAL
OWNERS AGENT v4_ 4_2 � BUILDING OR WORK
ADDRES '""`• ���`' '@ ... SEPTIC TANK,SEEP,PITS)
•-• AND/OR DRAINFIELD
I HEREIN ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION -
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWEL:L ❑
LCALIFORNIA
COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. .SEWAGE DISPOSAL SYSTEM
Y CERTIFY THAT I AM PROPERLY REGISTERED AND/ DISCONNECT PLUG AND
AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF .ABANDON HOUSE SEWER
IA OR THAT I AM THE LEGAL OWNER OF THE ABOVED RESIDENTIAL PROPERTY. F' BACKFILLSEPTIC TANKS 0ESEEP.PITS) ❑ CESSPOOLSITTE
VALIDATION ROBERT A. MOOD
GK. M.G.. CASH_; SUPERVISING MECHANICAL ENGINEER
L O :1 3 1 Sul- 3 1 -0 D 7.0 0