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CES013 362
76A6420 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
R_S
IDDRESS_ I . ..
JOHN A LAMBIE, County E lineer 0' 1;d4 cz IR -67k IV`
WLLIAM A.
JENSEN, Supt of" ulding py
LOCI�LIT y
R
L AR F S T
2�_
FOR APPLICANT TO FILL IN CROSS ST*
DESC
LOT NO. OWNER
MAIL
BLOCK
ADDRESS
NO. OF BLDGS.
SIZE OF LOT NOW ON Ll--)l CITY T.L. NO.
,.ISE OF
BUILDiNGS DISTRICT NO. GROUP MAP �ROCES��FQI MY
SK P
CONI R4 TOR
JI
ADDRESS L , 1-i CTION D;
teCITY G, _NU_ ; STA DEPTH
-3-7TA-� MAN...STATION
11.1E.1,11C'r
C,
REGISTRATION NO. s U,',Ty
No GES RI�TION OF WORK FEE TYPE OF CONNEETION LENGTH F51&M
—tHousi-siiw'ER C:6N-NE'C TING TO Y. CURB L. TO P.]
F PLIC S E WER $5.00
OR
SEPT€0 TAN K. MT PC NO NO.
O.
P17S AND/OR DRAINPIc.LD N
$70,00
it USE SEWfP CON NE TIN TRUNK PERMIT NO. ROAD PERMIT NO, 0
PRIVATE DiSPOSAL SYSTEM @ 33,00
ONNECTADDITONALSLDG OR AFFIDAViT—!-WAiVl-R LA.SEMC.Il INS-R.NO. DA
VV")RK'r0
3RK'ro HOUSE SLWER @ $3.00
0 V E.14 FLOW I SEEPAGE`SIT,rstAiNpir-LD 4L
F�XT'4..CESSF�OL.DRYVv-ELL.MAt,!,iOLC :33.00
HWY. OR ST.W!DENING
ALTER.
SFWER OA-A=.SEQA—L SYSTIM @ $3 DO
.,TATE.ENCROACHME NT
PFRMIr NO.
Q INOU
_J R I�1�L A
'14ARGES
OWNER'S PERMIT 2 00
N�4-
CONNECTIO A RGE FEE
AUTHORIZATION TOTAL FEE > -2- " - —------
I HAVE AT THIS DATE A T'
CONTRACT WITH HE HEREIN NAMED CON- REIMSURSEPAIENT FE-E
TRACT0FR TO
Co NNECT THE ABOVE DESCRIBED EXiSl ING DWELLING
TO IriF PUBLIC &EWFR. APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED 'THIS DAY
OW ER OR NEW HOUSE SEWER
OWNERS AGENT--,--.---- CONNECT ADDIT40NAL
BUILDING OR WORK
A D
SEPTIC TANK,SEEP,P T(S)
IH F:RFBY ACKNOWLEDGE THAT I HAVE READ THIS ADPL R
ICATION AND/OR DAiNFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
'WITH ALL COUNTY, ORDINANC,-15 AND STATE LAWS REGULATING
J'JS CESSPOOL F1 DRYWFLL
PLL; �NG AND 5EW r_RS,
HLREBY CERTIFY THAT PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
I 'kM
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF' SEWAGE DISPOSAL SYS'T'EM
C LIFORNfA OR THAT I AM THE 1. A_ O�NNER OF, AND INTEND TO
A v'F'al R [31SCONNECT PLUG AND
RESIDE IN, rHE. C rf, EIANOON HOUSE SEWER
SIGNATURE ---L
AlKl.iLL SEPTIC TANKS ❑ I
SEEP,n,t(5" 0 CESSPOC—S F-7�
,V, ALIDATION ROBERT A. WOOD
/CK M.G. CASH SUPERVISING MECHANICAL ENGINEER