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76AE4 D60 APPLICATION FOR PER1lPt'e1T
76Ao42COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL l
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
TORN A. LAMBIE, County Engineer
WILLIAM A. ]ENSEN, Supt of Building LOCALITY J�'
NEAREST t.._ .•ate ...
FOR APPLICANT To FILL IN
LEGAL
DESCRIPTION LOT NO _� :-� . P r_i. � OWNER
BLOCK TRACT �'" MAIL
ADDRESS
NQ.OF BLDGS.
SIZE OF LOT NOW ON LOT CITY"Y i?. TEL N0,
USE OF j y „ DISTRICT N0. GROUP MAP PROSESSEp$Y
BUILDINGS
CONTRACTOR .;' i�/ rte` R- �! .F'�> p 1 !,. 41
ADDRESS . - CONNECTION DATA/
CITY ) STATION° i TEL.NO. LL '4 DEPTH >_ g
`i ✓; �
d STATE MANHOLE REFERENCE 4 llPFl«R..
REGISTRATION NQ. t/ -' ,- �:
P r,. COUNTY .."g LOWER
NO, I DE SC tIFTIaN! F WORK FEE
d HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $9.00
TYPE OF CONNECTION LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR Y. CURE P.L. M.L,TO P.L.
PITS AND/OR DRAINFIELD @ $9.00 y
OVERFLOW SEEPAGE FIT, DRAINFIELD
ERTN.. CESSPOOL DRYWELL @ 52.00
HO 5E SEWER CONNECTING TO P.C.N0,
PRfVATE DIS.?OSAL SYSTEM @ $1.00 CO.1MP. NO. .f -• " a.,✓ JOB NO.
CONNECT A.DDIT!ONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT N0. 6` s @ O
WORK TO HOUSE SEWER @ $t.00 ""� U
ALTER,REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
SEWER.OR DISPOSAL SYSTEM t 31,Q0 PERMIT NO. O
INDUSTRIAL E"
WASTE.APPROVAL iUsl
CHARGES
OWNER'S PERMIT $ 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FIX °' 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 dvDAY OF 19e NEW HOUSE SEWER
OWNER OR C
ONNECT ADDITIONAL
OWNERS AGENT - DING OR WORK
r ..>
ADDRESS__. C TANK,SEEP.PIT(S)
--- — OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLYPOOL [] DRYWELL. []
WITH ALL COUNTY ORDINANCES AND STATE' LAWS REGULATINGR;REPAIR,SEWER OR
PLUMBING AND SEWERS. GE DISPOSAL SYSTEM
! HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/ORNNECT PLUG AND
LICENSED AS'. REQUIRED BY LOS ANGELES COUNTY AND STATE OFDON HOUSE SEWER
CALIFORNIA OR THAT I AM T14E LEGAL OWNER OF THE ABOVEDESCRIBED RESIDENTIAL PROPE4Y FILL SEPTIC TANKS []SIGNATURE PIT(S) LJ CESSPOOLS
Er t5�' �,�°OF PERMITTE a''°
r - VALIDATION-' ROBERT A. WOOD
CK. U.0. lCASH SUPERVISING MECHANICAL ENGINEER
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