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6A642D APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER SEWER-SEWAGE OISPOSAL
BUILDING AND SAFETY DIVISION S J 1 LDING
A DRESS JOHN A. LAMBIE, County Engineer 2 e
WILLIAM A. JENSEN. Sup't of building
LOCAL)TY
NEAREST
FOR APPLICANT TO FILL IN rl'.0.5 IT. A
CESCRIPTION
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CONNECTION DATA
STATION DEPTH
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'6TATE
RCGISTRATION NO. Y' COUNTY MANHOLE REFERE.NCE
NO, DES CRI Pm OF WORK FEE TYPE OF CONNECTION LIENGli FROM.
HOUSE SEWER CONNECTING TO Y CURB P,L. M.L.TO P.L.
PUBiP.C.NO.
C SEWER 1,5,00
SEPTIC TANK.SEEPX6i_PIt'®R CO.IMF.NO. Job NO.
PTS ANO/OR DRAINFIELD $10.00
TRUNK PERMIT NO. ROAD PERMIT NO,
FRiVATE DISPOSAL SYSTEM $3,00
CONNECT ADW71ONAL BLDG.OR. AFF:&;w)T F;;x'�117 ";i� wt:'Z6R. "Si.w NO. DATE
l'LjR - WER $a.00
0 HOUSE
SE
OVERFLOW
EXTN.,CESSPOOL,RRYWLL,MANF.OLE $8.00
--'-AI REPAIR OR ABANDON H-5—L"SE Hwy�OR ST.WIDENING
R DISPOSAL SYSTEM @ $3.00
WKR 0 J
STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OVMER'S 2 00
AUTHORIZATION LToTAL FEE CONNECTION CHARGE.FEE
I HAVE AT THIS DATE A CC)NrRACT WITH. THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE: ABOVE DESCRIBED EXISTING DWELLINGTo T J'4 5 P UBLIC SEWEr. APPROVALS DATE SIGNATURE
SIGNED THIS —DAY OF—
OWNER'DR NEW HOUSE SEWER
OWNERS AGENT--_
���NNE CT ADD!-, ONAL
BUILDING
G OR WORK
ADDRESS'
SCPIICTANK,S EEP,PIT(S)
iHRRI�13Y ACKNOWLITOOK THAT I HAVE READ THIS APPLICATION AND/OR DRAINPIELD
ANC
THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY -------
H ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS, CESSPOOL. ❑ DRYWELL
IHEREBY CERTIFY THAT I AM, PROPERLY REGhSTERCD ANr,/oR ALTER,REPAIR,SEWER OR
LICENSED AS REPI)N'ED BY LOS ANGLES COUNTY AND STATE: OFA SEWAGE DISPOSAL SYSTEM
CALIFORNIA4,,.'tAT,,i AM THE SLEGA 0YINIER PoF. Al-ID INTEND TO
DISCONNECT PLUG AND
RES,DE IN, E DESCRIBED R"_N T?,\L PROPERTY.
ABANDON HOUSE SEWER
SIGNATURE
_CKFIkL SEPTIC;TANKS Cl
OF PERM _j3^- -
7-/ SFFP.PIT(S) CESSPOOLS IQ
VALIDATION ROBERT A. WOOD
CK. M.0. CAS SUPERVISING MECHANICAL. ENGINEER
0 4 7 5