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7r,A6420 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION B IL.DING 4-
JOHN A. LAMBIE, County Enc'neer
WIT-LIAM A. JENSEN, Sup't of Building
LOCALITY
NI EAREST
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FOR ADPPCA.NT TO FILL IN CROSS ST�
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ADDRESS CONNECTION DATA
CITY
STATION DEPTH
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STATE TE MANHOLE REFRENCE >
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REGISTRATION N!G. CLOWER
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NO. DESCRIPTIO, F WORK FEE TYPE OF CONNLCTiON LENGTH FROM
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PUBL!(:S nw Ey�
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SEPTIC TANK SEEPAGE PIT
PITS AND/or-,DRAINFIEE-1-1 @ sio.00 CO,]NIP. NO. J 0 B NCI. 0
7 N TO
TRUNK PERMIT NO. ROAD PERMIT N&
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PRiVATE DISP09AL SYSTEM @ $3.00 1
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CGN N-6,-T-A-D-D-1-Ti ANAL RL DG.OR T- (A.
WORK TO HOUSE SEWER @ $3.00 AIVER EASEXENY PFCORD. INSTR,NO, DATE
OVERFLOW SEEPAGE PIT,DRAINFIELO z
FXTN @ $5.1)0
Hwy. aj
ALTER,REPAIR OR ABANDON HOUSE
SFWER ORDISPOSAL SY5TEW.
$3.00 STATE 411
PERMI
NO,
INDUSTRIAL
WASTE APPROVAL
CHARGES
OVMEWS PERMIT 2 00
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE
i HAVE AT THIS DATF A CONTRACT WITH THE HEREIN NA.Il-
Il— c ON, REIMBURSEMENT FEE.
TRACTOR T ONNECT THE AnOVE DESCRtOED EXISTING
DW E LL
APPR, I -rA-TE 11--INSPECTOR'S SIGNA4UPr
0 C 1ND --T
TO THE: PUBLIC SEWER.
SIGNED THIS —----- -4
OWNER OR NEW HOUSE SEWER
OWNERS _
CONNECT ADDITIONAL
BUILDING OR WORK
SEPTIr TANK.SEEP,PIT(S)
I HERESY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
'
AND STAVE THAT THE ABOVE. IS CORRECT AND AGREE TO COMPLY
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMB
INC AND SEW C RS. CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT 2 i.M PROPERLY REGISTERED AND/OR ALTER,-REPAIR,-SE'NE.R OR
CENSE D AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM 'THE LEGAL OWNER OF. AND INTEND TO
DISCONNECT PLUG AND
14ESIOE THE Aa'6�E DF5CR.IBEO RFSIQ!f:NTl PERT 1 0
IN. a6 j ABANDON HOUSE:SEWER
SIGNATURE
OF PERMITTEE BACKFILL SEPTIC TANKS
SEFF,PIT(S) ❑ CESSPOOL$
VALIDATION ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
CK. M-0. CA!3H
4
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Cesca 10-62
78A642D APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER SEWER-SEWAGE DISPOSAL U
BUILDINNG ANT) SAFETY DIVISION 'BUILDING
ADDRESS
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JOHN A. LAMBIE, County Engineer
WILLIAM A. JENSEN, Sup't of Building
--
LOCALITY
OCALI TY
7NEAPE.-
FROS ST�
FOR APPL1,9ANT TO F
,,V.L IN
V
07 NO. )WNER
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K TRAC"/
16
CAL
DESCRI i
NO OF
I1LLDG5.
,A)w 0
S!z" OF T N OT CITY TEL. NO.
USE Or
SU.IL-DINGS DISTRICT NO. GROUP BK MAP PG PROCESSED BY
CONTRACTOR,_ 'v
AODRESS /7 CONNECTION DATA
STITI.N DEPTH
0,
TEL. N
jtlPE
TN NO. T�. Ty 4T.E: IVIANH-LE'R
REGISTRAIO 'E51ERENC�
LOWER
0
Ne. DESCRIPTION OF WORK FE ETYPE OF CONNIECTiON LENGTH FROM
I HOUSE SEWER CONNECTING TO Y. P:.L. M.L..TO P.L.
PUBLIC SEWER $5..00
NO.
1. - �11
SEPTIC TAN ,AGE R JOB NO,
PfTS AND/O�DRAINFiELD $10.00 C.O. 1 M 1NO
HOU'E SEWER CONNECT'NG TC, TRUNK PERMIT NO, ROAD PERMIT NO.,
PRIVATE DISPOSALSYSTFM yj
C
0-
DATE
0N.111CT A0 Ti0i BILL——OR .4 lf�fDAV I T WAIVER KASEME��T
WORK 10 ric'�SF 3E"-:7 @ $3.00
OVERFLOV'jEEPAUIF PIT,ORAINF�iEL6
HWY.OR ST.WIDE
WNG,
ALT EPAIR OR ABANDON HOUSE
�E TE M
STIATE ENCROACHMENT
)R DISPOSAL��YG3
PERMIT NO.
INDUSTRIAL
WASTE AFFROVAL
OfvNErrs PERMIT IS! 2;; 00
C.NNF-CT!-,)N CHARI:1E FEE
AUTHORIZATION TOTAL FEE
I HAVE AT THIS DATE A CONTRAGT WITH TP E HEREIN NAMED CON- REIMBURSEMENT FEE
RACTO ONNECT THE A90VE DESCRIBED EYISTIN�G DWELLING ------
T -
! '
TO THE PUBLIC, FEWER. LS DATE INSPECTORS SIGNATURE
SIGNED THIS DAY 9
OWNER OR NEWHOU SE SEWER
OWNERS CONNECT ADDITIONAL
AU iL DING OR WORK
SEPTIC TANK,SEEP,PIT(5)
I HERFBY ACKNOWLEO'GE -,HAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELO
AND STATE THAT THE ABOVE IS I-ORRECT AND AGREE TO COMPLY
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PIUMB IN AND SEWE.R5. CESSPOOL DRYWELL C]
HEREBY CERT!" THAT I AM PROPERLY REGISTERFO ANO/OR ALTER,REPAIR,SEWER OR
LICENSEE) AS REQUi RED BY 'LOS ANGLES COUNTY AND STATV. OF SEWAGE:DISPOSAL SYSTEM
CALIFORNIA 0 R THAT I AM THE LEGAL OWNER OF. AND INTEND TO SCONNECI PLUG AND
RESIDE iN. -,HE ASO , DESCRIBED RESIDE PROPERTY-
ABANDON HOU5E SEWER
LI GNATUIRE
VACKFiLL SEPTIC TANKS
SEEP,PIT C9) CI CESSPOOLS
VALIDATION ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
CK., M.O. CASH
5C,