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CE8080 Be APPLICATION FOR PER IT 1
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
LOAN A LAMBTE County Fn ... ADDRESS
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CA99A7S D GBTPFlN Sup t o7 Burldwq LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS sT
LEGAL
DESCRIPTION LOT NO OWNER
BLOCK TRACT MAIL
ADDRESS
NO OF BLDGS
SIZE OF LOT NOW ON LOT CITY TEL NO
USE OF
BUILDINGS DISTRICT N/Or7 GROUP I MAP PROCESSED BY
CONTRACTOR) /� i' �� -:o— d y _ PG
ADDRESS / py.�, C/ CONNECTION DATA
CITY TEL NO 4f
STATION DEPTH
ATE
REGISTRATION NO A% •7 COUNTY MANHOLE REFERENCE UPPER
NO D SCRI T O K FEE LOWER
l
HOUSE SEWER CONNECTING TO
PUBLIC SEWER q 13 DO TYPE OF CONNECTION LENGTH FROM
SEPTIC TANK SEEPAGE PIT OR T CURB P L M L TO P L
PITS AND/OR DRAI NFILD $3 00
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL MANHOLE P 00
HOUSE SEWER CONNECTING TO P C NO
PRIVATE DISPOSAL SYSTEM a $1 00 CO IMP NO JOB NO
CONNECT ADDITIONAL BLDG OR TRUNK PERMIT NO ROAD PERMIT NO
WORK TO HOUSE SEWER Q $1 00
ALTER SEWER OR REPAIR
SOR YSTEM NDON HOUSE $I 00 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
MI
OWNEWS PERT s 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE &V REIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON APPROVALS DATE INSPECTOR S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER ^
SIGNED THIS DAY OF I9_ NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL e
OWNERS AGENT BUILDING OR WORK
SEPTIC TANK SEEP PIT(S) ol
ADDRESS AHD/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL Q DRYWELL 0
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
1•HEREBY CERTIFY I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS RED EI Y LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR AT AX TXE LEGAL OWN OF THE ABOVE
DESCRIBED REST TI PROPERTY (� BACKFILL SEPTIC TANKS 0
SIGNATURE f A SEEP PIT 5 CESSPOOLS
OF PERMITT �
®r - ALIDATION ROBERTA WOOD
M o CAIN SUPERVISING MECHANICAL ENGINEER
Lfo7 6 6 1 �tl ?6 1 s D 3 CIU
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