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18AA6420 APPLICATION FOR PERI AT y
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING -
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS
COLEMAN W. JENKINS, SUPT. OF BUILDING
LOCALITY / (F! �
NEAREST t
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL
DESCRIPTION LOT NO. OWNER A-,,/
MAIL 1
- BLOCK TRACT
NO. OF SLOGS.
SIZE OF LOT NOW ON LOT C CITY TEL. NO.
USE OF
BUILDINGS DISTRICT NO. GROUP MAP ='P 68ED BY
_ BK PG 8
CONTRACTOR r,+
ADDRESS y ter' ;,� CONNECTION DATA
. � STATION DEPTH
CITY - A s' {,1 TEL. NO. F�s {� �v0 �� _
"-7 j .� �...fi�e"'..... ..
STA E _ :' CL.SS 6 MANHOLE REFERENCE
LICENSE NO: 4"� - ,�' � � (_
__ L6WER
NO. DESCRIPTION OF WORK FEE TYPE O�.GAF�flYC(tON LENGTH FROM
—___—
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L. _,
PUBLIC SEWER @ $F-0o �✓' - - P.C.NO.
r--TSEPT! TANK—SEEPAGE PIT OR .
PITS AND OR DRAINFIELD @ $10.00
1 CO. IMP,NO. J08 NO.
HOUSE SEWER CONNECTING TO 1 J
PRIVATE D.SPO SAL SYSTEM @ S3.00 TRUNK PERMIT NO. ROAD PERMIT NO. _
_ _ _ _ _ _ _ J e . Q
CONNECT ADDITIONAL BLDG.OR —T AFFIDAVIT TWAIVEII EASEMENT RECORD.INSTR.NO, DATE U
WORK TO HOUSE SEWER @ $3.00
L -- - ------- - - ------ 1__ ------ -L __
OVERFLOW SEEPAGE PIT,DRAINFIELD
I EXTN..CESSPOOL.DRYWELL.MA NH OLE @ $5.00
ALTER.REPAIR OR ABANDON HOUSE -- HIVY.OR ST.WIDENING W
-_-- �
SEWER OR DISPOSAL SYSTEM $3.00STATE ENCROACHMENT �)
PERMIT NO.
INDUSTRIAL
����NE+ IT
WASTE APPROVAL
O'WR'S PERM `_ 00 - --- CHARGES
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL. FEE L-0 -- ----- - -
I HAVE AT THIS DATE A CONTRACT WITH THE HEREINAMED CON- REIMBURSEMENT FEE
TRACTOR TO-CONNECT THE ABOVE DES iBED EXISTING DWELLING �/ c
70 THE PUBLIC SEW Eft. IZ�- APPRO YALJ DATE iN5P TOR'S�NA TURE
SIGNED THIS DAYOF'' :Y l ---"—`—`— _OWNER OR�,--yy-� NEW MOUSE SEWER
OWNERS AGEN' y"v� .�-4_� .`'Y�-,Cvl-y+rxx CONNECT ADDITIONAL
-
BUILDING OR WORK
ADDRESS
T— SEPTIC TANK.SEEP,PIT(S)
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ElDRYWELL ❑
I HEREBY CE=RTIFY .AT I AM PROPE RLYlREGiS'FRED ANDI OR ALTER,REPAIR.SEWER OR
LICENSED AS RIEQUIRED Y LOS ANGLE$ COUNTY D STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I Ahk THE LEGAL OWNER OF, A D INTEND TO DISCONNECT PLUG AND
RESIDE IN. THEASO E D CRIBED SIDENTIAL P PERTY. ABANDON HOUSE SEWER ✓y y
SIGNATURE _'7
--- - y
OF PERMITTEE " BACKFILL SEPTIC TANKS ❑ /'
SEEP,PIT(5) ❑ CESSPOOLS
VALIDATION JACK R. ALLEN
rr.K. w 0. CASH SUPERVISING MECHANICAL ENGINEER
.K. M.O. CASH
T .� rZi
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