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8A6421) APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN Ag LAMBYE, County Eaggan®er ADDRESS o'
WILLIAM A. JENSEN. Su
of 8nalding LOCALITY r �`
NEAREST
FOR APPLICANT TO FELL IN CROSS ST.
LEGAL OWNER P i.
DESCRIPTION LOT NO,
BLOCKMAIL
TRACT
ADDRESS
NO.OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO
OF
BUIE DINGS DISTRICT NO. GROUP MAP PROCIPSED BY
BK PG
CONTRACTOR ,
,ADDRES '` ,# a_�--- CCINNECT'ION DATA
J f
Ca /s. TEL.NO., . d ! S�A ON ✓ DEPTH
tf y STATE MANHOLE REFERENCE<- i r UPPER
REGISTRATION N0, COUNTY ! -
VZ
NO. 1 DESCRIPTION OF WORK FEE
1
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $0.00
TYPE OF CONNECTION LENGTH FROM
S PTICTANK,SEEPAGELDPIT OR . 5.00 '- Y. CURB P.L. M.L<TO P.L. --
OVERFLOW SEEPAGE PiT,DRAINFIELD
EXTN..CESSPOOL.DRYWELL @2.00
HOUSE SEWER CONNECTING TO / L P.C.NO,
PRIVATE DISPOSAL SYSTEM 1.00 CO.IMP NO. JOB N0. C�
CONNECT ADDITIONAL BLDG.OR
WORK TO HOUSE SEWER @ 1,00 TRUNK PERMIT N0. ROAD PERMIT NO
ALTER,REPAIR OR ABANDON HOUSE STATE ENCROACHMENT 9—
SEWER OR DI.POSAL SYSTEM C>+Si.00 PERMIT NO,
INDUSTRIAL
WASTE APPROVAL
CHARGES ?
MEWS PERM $ 2 OO CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE / REIMBURSEMENT FEE
IHAVE AT TRACTOR TO CIONNECT THE ABOVE S DATE A IDESCRIBED EXISTING DWELLING WITH THE HEREIN�NAMED CON- APPROVALS DATE INSPECTOWS SIGNATURE
TO THE PUBLIC SEWER. —
SIGNED TRIS DAY OF 19s 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 AND AGREE TO COMPLY CESSPOOL Cl DRYWELL 13
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 SEWER
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOYE
DESCRIBED RESIDE7rIAL P. PERTY. r r BACKFILL SEPTIC TANKS ❑
SIGNATURE / PIT(51. CESSPOOLS
OF PERMSTTE mow' a ._ ! r y r
,<-NAIMATION _. ROBERT A: OOt3
CK. i Y.O. CASH SUPERVISING MECHANIC.AL.ENGINEER
34650 INSERTS 9y�
i
7aA642D
APPLICATION FOR PERMIT
sazo COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL l
DEPARTMENT OF COUNTY ENGINEER
BUILDING ANIS SAFETY DIVISION su1LDING�,
AD➢KESS
JOAN A. LAMBIE, County En ineer
WILLIAM A. JENSEN. Supt of Building LOCALITY '
FOR APPLICANT TO FILL IN
CROSS 577E
LEGAL "
DESCRIPTION LOT NO. OWNER
BLOCKMAIL
_ ,,,: TRACT ":1 ADDRESS
NO.OF BLDGS. -
SITE OF LOT NOW ON LOT CITY TEL, N0.
USE OF
ILDCNGS DISTRICT NO. GROUP MAP PROCESS BY
BK PG
BU
CONTRACTOR;,
r d
ADDRESS f « u y. .,., > e CONNECTION .DATA
CITY TEL.N0. y&. d' A ON
y` :' '3`TATE MAN H0 Li R FERENGE
_ r rA
REGISTRATION N0.
COUNTY ✓ s
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO !`
PUBLIC SEWER - @ $3.00 TYPE OF CONNECTION LENGTH FROM_. ,f -
SEPTIC TANK,SEEPAGE PIT OR Y. CURB P.L. M.L.TO P.L. _
PIPS AND/OR DRAINFIELD @ $3.00 .Y
OVERFLOW SEEPAGE PIT.DRAINFIELD
EXTN., CESSPOOL ➢RYWELL @ $2.00 P,C.NO.
'
HOUSE SEWER CONNECTING TO CO. MP, NO.: ! �
PRIVATE DISPOSALS STEM @ $1.00 _ f" 30B N0.
CONNECT ADDITIONAL BLDG.OR
WORK TO HOUSE SEWER @ $1.00 TRUNK PERMIT NO. ROAD PERMIT NO:, �.r �' v
ALTER,RrPAIR OR ABANDON HOUSE STATE ENCROACHMENT - pq
SEWER.OR DISPOSAL SYSTEM @ $1.00 PERMIT NO. H
INDUSTRIAL W
-'� WASTE APPROVAL
_-_-- CHARGES
OWd Ni ER'S _PERMIT 5
✓ CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE ' i, ��` REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE 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
I HEREBY ACKNOWLEDGE THAT' i HAVE READ THIS APPLICATION
AN➢ STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL ❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ER,REPAIR.,SEWER OR
PLUMBING AND SEWERS, SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDONHOUSET USE SEWER
CALIFDRNIA OR THAT I AM THE LEGAL OWNER OF TH ABOVE
DESCRIBED RESIF) AL P12PERTY. , BACKFILL BE TANKS OL
SIGNATURE SEEP-PiT(S) ❑ CESSPOOLS i
OF PERMITTEE x. �_C-^"' a'`_ r _
�° VAL3DATION ROBERT A. WOOD
X.o. CASH SUPERVISING MECHANICAL ENGINEER
Lo
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