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S&E.613 APPLICATION FOR PERMIT
DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Department of County Engineer 1 11 lie
County of Los Angeles BUILDING
ADDRESS
JOHN A. LAMBIE, COUNTY ENGINEER
CASSATT D.GRIFFIN, SUPT OF BUILDING LOCALITY,
EAREST
FOR APPLICANT TO FILL IN "ROSS ST
LEGAL
i D N IPTIOLOT NO. OWNER
MAIL
BLOCK TRACT
A DRESS
-NO.OF BLDGS.
�NOW ON LOT
SIZE OF Lor CITY 2 TEL. NO."i-
USE OF'
BLLD'-N G 5DISTRICT NO. ASAP
AP
,
BK PG
CONTRACT OR
ADDRESS CONNECTION DATA
I '- r s; STATION DEPTH
CITY TEL NO. ------
MANHOLE REFERENCE
,e STATE
REGISTRATION NO. COUNTY
NO. 1 DESCRIPTION OF WORK
--h --- -- -- -- -- TYPE OFr."?,ICCTION LENGTH FROM
HOUSE SEWER CONNECTING TO y
PUBLIC SEIIV�R 3.50 :CU
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD (4, $3.40
67vkk-FL-QW-sEizP-A GE PIT,GRAINFIELD P. C. NO.
EXTN.,CESSP3OL,DRYWELL,MANHOLE 2-00 CO, IMP. NO.
HOUSE SEWLR CONNECTING TO
PRIVATE DISPOSAL SYST EM $1.00 TRUNK PERMIT NO. ROAD PERMIT NO.
CONNECT ADDITIONAL BLDG.OR STATE ENCROACHMENT--_- -_.-_.-_-._.
WORK TO HOUSE SEWER q, $1.00 PERMIT NO.
7-7-
ALTER,REPAIR OR ABANDON HOUSE ~- INDUSTRIAL
SEWER OR DISPOSAL SYSTEM (T( 1.00
WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNEWS PERMIT IS 1 00
REIMBURSEMENT FEE
AUTHORIZATION
TOTAL FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- ---APPROVALS DATE INSPECTOR'S SIGNA'rURE
TRACTOR To CONNECT THE, ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER, NEW HOUSE SEVER
SIGNED THIS BAY OF--sa 19
CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK
OWNERS AGENT -,�-4
SEPTIC TANK,SEEP,PIT(S)
PNDi OR DRAINFIELD
1 HER FBY/,ACtNOtDGE THAT 1H�AVREAD T 5 APPLICATI,1
AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY CESSPOOLO DRYWELLO
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING {'' � �A
ALTER REPAIR,SEWER OR
PLUMBING ANU SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY ',ERI!F:Y THAT I ANI PROPERLY R"I`IiTERrD AND/OR
OR -------
LICENSED As REQUIRED RY LOS ANCELFS COUNTY AND STATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT.; THE L-ZG�-L OWNER OF' THE --ABANDON-HOU-SE SEWER.
, I AM ABOVE
DESCRIBED R.ESiDENT*AL PROPERTY. BACKFILL SEPTIC TANKS
A-
5 1 G IN A T UI IR E SEEP.P11 iS) Ll CESSPOOLS I I
OF
"R',TT4
OF PERM ITTZE'
M=-i,0
JOHN A. LAMBIE,C-�9ALfNTYENGINEER �VALIDATION [ROBERT A.WOOD, CHIEF PLEIG. UASFECTOR
CKA5H
4 10 A 4.5