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`6802`60 - APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS -+
JOHN A z AMB1E. Couaxty Engineer
Td ¢I
WII14NI A IENuEN, Supt of Building LOCALITY
FOR APPLICANT TO FILL IN GROSS ST,NEAREST e°<
Y
LEGAL
DESCR-IPTION LOT NO k .::I`-F f -€` OWNERMAIL
BLOCK TRACT '. ;/' ADDRESS
NO.OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL. N0. I%'`USE OF I
/ d'
BUILDINGS DISTRICT N0. GROUP MAP PROFESSED
.BY
PG ;K
CONTRACTOR- ..( -
ADDRESS 71 CONNECTION DATA
%i° ^..� P STATION r F
CITY TEL.N0. ' ,, �_ �, i DEPTH a
STATE MANHOLE REFERENCE j 4 UPPER
REGISTRATION N0, ,�,� � GOUNTY �. 1 ;/
NO. I DES CRIP _ F WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER C1 $3_00 TYPE OF-CONNECTION LENGTH FROM
SEPTIC TAN SEEPAGE PIT OR Y. r" CURB P.L. M.L.TO P,L.
PITS AND/OR D_RAINFIEL.D @ $3.00 -
OVERFLOW SEEPAGE PIT. DRAINFJELD 'T
EXfN,.Cc"SPOOI. DRYVlELL `a 32.00
HOI.SE SEWER CONNECTING TO / ," --Fr P.C.N0.
PRIVATE DISPOSAL SYSTEM @ $1.00 CO, IMP.NO.. -� JOB NO.
£ONNEC7 ADDtI'iONAL BLDG.OR 's.$$1,00 ,,'. TRUNK PERMIT NO. ROAD PERMIT N0,
WORK TO HOJSE SEWER C?
ALTER, REPAIR OR ABANDON HOUSE , STATE ENCROACHMENT k=
INDUSTRIAL
DISPOSAL SYSTEM @ $1-00 PER Rt IT NO. O
INDUSTRIAL L))
_ WASTE APPROVAL W
CHARGES w
OYIMER'S PERMIT $ 21 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE r REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TOCONNECT 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
iI } .� .?_y. .y- SEPTIC TANK,SEEP,PIT(S)
ADDRESS - AND/OR DRAINF•IELD
I HEREBY ACKNOWLEDGE THAT IHAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CO9RECT AND AGREE TO COMPLY CESSPOOL I] DRYWELL
L
. COUNTY ORDINANCES AND STA'L'E LAWS REGULATING ALTER,REPAIR,SEWER OR
AND SEWERS. SEWAGE DISPOSAL SYSTEM
Y CERTIFY THAT I ADS PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
IA OR THAT I AM THE LEGAL OWNER OF THE ABOVE
D REBID TIAL P PERTY. ^3 BACKFILL SEPTIC TANKS ❑
ESEEP,PIT(5) CESSPOOLS
ITTEE'
DF VAUD.ATION.a ROBERT A. WOOD
CK. m,0. ;CASH SUPERVISING MECHANICAL ENGINEER