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6A64.8 APPLICATION FOR PERMIT 1
COUNTY OF Los ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING: AND SAFETY DIVISION BUILDING .
JOHN A. LAM$IE, County Engineer ADDRESS
J
CASSAIT D. GRIFFIN. Sup t,of Building LOCALITYNEAREST
FOR APPLICANT TO FILL IN __CROSS ST.LEGAL
DESCRIPTION LOT N0, +' .r OWNER #..-,,.` ,�^;r#,>`� „
BLOCK TRACT MAIL
0 ADDRESS :7
NO. OF BLDGS.
SIZE OF LOT NOW ON LOT w CITY TEL,N0.
USE OF �
BUILDINGu� .-{d t, " ,,,.,x,1'1,, . ' ,,'� DISTRICT NO. GROUP MAP PROCESSED BY
BK PG
CONTRACTOR
ADDRESS _ CONNECTION DATA
�'
CITY < STEL NO ATION DEPTH
— r6 � "'.1 TATE MANHOLE REFERENCE UPPER
NO. i
REGISTRAT.ON NO. _ r COUNTY LOWER
PLSCRIPTlU. CPF '+hrORK.- FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3.00 TYPE OF CONNECTION LENGTH FR
SEPTIC TANK.SEEPAGE PIT OR Y, CURB P•E:a M.L.TO
P.
PITS AND/OR DRAINFI£LD @ $3.00 _
OVERFLOW SEEPAGE PIT, DRAINFIELD
ER:TN.,CESSPOOL,DRYWELL,MANHOLE @ $2.00 `-
HOUSE SEWER CONNECTING TO P.C.NO.
PRIVATE DISPOSAL SYSTEM @ $1.00 CO.IMP.N0, JOB NO._
CONNECT ADDITIONAL BLDG OR a
WORK TO H01JSE SEWER @ $1,00 TRUNK PERMIT NO. ROAD PERMIT N0.
ALTER,REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
SEWER OR DISPOSAL SYSTEM @$1,00 HERMIT NO. N 1 4
INDUSTRIAL
WASTE APPROVAL "
_ CHARGES
ONET£{a PERMIT 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE 5 r '8 REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON.. APPR®VAI.S ' DATE INSPECTOR'S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DES IBED EXISTING DWELLING
TO THE PUBLIC SEWER>
SIGNED THIS-----------D- _G)F �.99�_ NEW HOUSE SEWER
OWNER OR j CONNECT ADDITIONAL
OWNERS AGENT _BUILDING OR WORK
SEPTIC TANK,SEEP,PIT(S)
ADDRESS__ _ AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORREC AND AGREE TO COMPLY CESSPOOL CI DRYWEI_L
WITH ALL COUNTY ORDINANCES AND ATE LAWS REGULATING ALTER, REPAIR,SEWER OR
PLUMBING AND SEWERS. _SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY jTWAT I AM P PERLY REGISTER r AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS J+_ EL COUNTY AN STATE OF ABANDON HOUSE SEWER
CAIIFO lA OR AT I AM TiW` R OF HE ABOVE
D 'ED RESID NTIAL PROPO SACKFILL SEPTIC TANKS❑
!) SEEP, PIT(S) [] CESSPOOLS
VALIDATION,,-- ROBERT A.WOOD
CK, M.a< jcASH - SUPERVISING MECHANICAL ENGINEER