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76A6421) /APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS _
IOIIN A. LAMBIE, County Engqineer.
WILLIAIMI A. JENSEN, Supt of Buffding LOCALITY ,
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL ,7 OWNER
DESCRIPTION LOT NO.
BLOCK TRACT '27 DRESS
NO.OF BLDG$. t5l _
SIZE OF LOT NOW ON LOT �^ `... C['a'r - ,.TEL. NO.
BUI 0 DISTRICT NO. GROUP MAP PROCESSED BY
KPq
CONTRACTOR ' 1� J) L
Ta�v'dTs`� e.Y ����r'`�.,'v`a,✓ ,�, _,l �L i"�' �
ADDREss C NNECTION DATA
CITY � ,.� ",�„ TEL,NO, ° !' STATION - DEPTH
STATE MANHOLE REF-ERENCE UPPER
REGISTRATION NO _ H COUNTY_ LOWER
NCL I DESC'RIP'TION OF WORK FEE
HOUSE SEWER CONNECTING 70
PUBLIC SEWER_ @ $3.00 TYPE OF CONNECTION , LENGTH FROM
SEPTIC TA SEEPAGE PIT OR Y. CURB a L. M.L.TO P.L.
PITS AND/OR DRAINFIELD n $3.00
OVERFLOW-SEEPAGE PIT,DRAINFIELD
cXTN. CFSS"001:. DR HELL. e $2.00
H)USESEW RCONNECTING'TO I P. NO.
PRIVATE: DISPOSAL 515TEl". C $1.00 _ CO. 19PP!N0. JOB N0. �
CONNECT ADDITIONAL BLDG,.OR TRUNK PERMIT N0. ROAD PERMIT N0.
WORK TO HOUSE SEWER C? $t.00 U
ALTER. REPAIR OR ABANDON HOUSE I STATE ENCROACHMENT
SEWER OR DISPOSAL SYSTEM SL00 PERMIT N0. 6
INDUSTRIAL V
WASTE APPROVAL w
Aa
s CHARGES
OWNERS MIT s 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE I C REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THEA OVE DES'C�IBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEW4
SIGNED THIS OF 18 NEW HOUSE.SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGE ` es+' BUILDING OR WORK
kD.DRESS._� ✓L � s'�.� SEPTIC TANK,SEEP,PIT($)
AND:/OR DRAINFIELD
I HERE8?-4CKNOWLEDGE THAT`l"HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL (]
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABR.NDON HOUSE SEWER
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS ❑
SIGNATrURESEEP.PITS) ❑ CESSPOOLS ❑
OF PERMITTEE.""
�F r VALIDATION ROBERT A. WOOD
CK. Y.o. CASH SUPERVISING MECHANICAL.ENGINEER
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