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76A6420 APPLICATION FOR PE IT �[
76A64lj
COUNTY OF LOS ANGELES SEWER SEWA DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING +� a
JOHN A. LAMBIE, County Engineer ADDRESS
WILLIAM A. JENSEN, Supt of Building
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CRoes ST-
LEGAL � V
DESCRIPTION LOT NO. _ OWNER �„/l—I- � _.
MAIL—
BLOCKTRACT _ ADDRESS
No. OF BLDGS. J
SIZE OF LOT NOW ON LOT' / CITY TEL. NO,.
USE OF t` DISTRICT NO. GROUP MAP ROC ED BY
BUILDINGS ff{'''
CONTRACT c,�-
ADDRESS CONNECTION DATA
�yy L s Z/a� f""'; DEPTH
CITY TE «. ✓i� .w' STATION
> I -7Iy'�) STATE MANHOLE REPERENCE
REGISTRATION NO. /'' y,i- _ y LI
COUNTY 'Ay OWE
NO. DESCRIPTION OF WORK FEE__ _ TYP •FC MNECTI } LENGTH ROM
HOUSE SEWER CONNECTING TO Y. �°` N L. M.L.TO P.L.
PUBLIC SEWER @ $5.00 - P.C.NO.
SEPTIC TANK,SEEPAGE PIT OR ( d
PITS AND/OR DRAINFIELD @ $10.00 CO. IMP.NO. JOB NO.
HOUSE SEWER CONNECTING TO O
PRIVATE DISPOSAL SYSTEM $3.00 I TRUNK PERMIT NO. ROAD PERMIT N j i V
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVER EAsrMENT RECORD.INSTR.NO. 'i DATE �
WORK TO HOUSE SEWER $3.00 ��- O
OV ERPLOW SEEPAGE PIT,DRAINFIELD W
EXTN,CESSPOOL.DRYWELL,MANHOLE @ $5.00
ALTER,REPAIR OR ABANDON HOUSE - HW
SEWER OR DISPOSAL SYSTEM @ $9.00 STA7yE'CE NCROACHMENT Z
'- -- -_--- PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES +.
OWNERS PERMIT $+ 2 00 --- - --
-- CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE 1 °/ l• s — --__
'IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN AMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING T�
TO THE PUBLIC SEWER, APPROVALS DAT III NSPECTOR'S SIGNATURE
SIGNED THIS DAY OF
OWNER OR NEW HOUSE SEWER -
OWNERS AGENT .s
CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS, _ ____ ------"--- --
SEPTIC.TANK,SEEP,PIT(S)
i HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY ------.------ ---
WITH ALL COUNTY ORDINANCE AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REG ISTE I D AND/OR ALTER,REPAIR,SEWER OR
LICENSED AS REQ BY LOS ANGLES COUNTY A STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA ORr"Z�
AM THE LEGAL OWNER OF, A D INTEND TO -DISCONNECT PLUG AND (-
RESIDE IN, THDESCRIBED R ENTIAL P PERTY. ABANDON HOUSE SEWER
51GNATU REw4 ACKFILL SEPTIC TANKSOF PERMITTE _ "- --- SEEP,PIT(S) ❑ CESSPOOLS ❑
VALIDATION ROBERT A. WOOD
CK. M.o. CASH SUPERVISING MECHANICAL ENGINEER
L! 7 7 L� CEO 2 1 J D 7.00-
6A6,�2i.': AF PLICA , ION 17OR PERMIT/ -
COQN Y OF WS A*jixF' :.'S
F,y. iTI��FNTOF
.. ta. r�rrTxx SEWER—SEWAGE DISPOSAL
BUILDING AND SAkEl r i.lv.al..� B'J!LDIN
..._
JOHN A. LAMBIE, County Engineer 4_)ORES
WILLIAM A. JENSEN, Supt of Building �
LO AI.ITY +
FOR APPLICANT TO FILL IN GR
LEGAL
DESCk �TIOtd L.UT NO �+ OWNER
BL 0 C K J`_'�.� TRACT r A1D o.•
NO .
OF SLOGS ",a,�T
SIZE OFLO7 'SOW Ohl LOT' - CITY ✓ TEL,. NO. `
USE OF
BUILD 14GDISTRIC f NO. G OUPI MAP PROCESSED BY
71
CO.
AODRESS CONNECTION DATA
c::T7 �,.�y. ,�++'°`' 7E ',•,•,.�y�e f' ". , ,�' STATION ,d' r DEPTH
•~- /q _
STATE MANHOLE REFERENCE
'- UPPER
.,--55 f F
REGIS 'ATI.ON NO ''. Sys. ,yj,�..� 1� s'CUNTY
No LE.:YCRIPTlOPJ F WORK FEE _ --- --- ---- ' --- _ --
�. S_ TYPE OF CONNECTION LENGTH FROM
'HO J5E EWER t:61`.NEC?ING Y .j CURB P.L. M L TO P.L.
r PUBLIC SEINER �° c 00 ! .=-�`.
-T SE PTfCY.A JK,SEEPAGE-PIT OR -._-'--__ �__ _.. CO IMP.NO. �J JUB NOr�
PITS AND/OR DRAiNFIELD 510,00 ._ 1✓� -.__—_ _-__
' Hq VA G EWE'2 CONNECT NG TO TRUNK PERMIT NO- ROAD PERMIT NO .�+°� '17�s
PRIVATE.DISPOSAL SYSTEM @ $3.00 V, ' :
CONNECT ZONAL BLDG OR I AFFIDAyIT wA:Vsq� ens[M[NTTRECURO. .NSTR NO. 1 DATE
WORK TO HO-.SE SEWER $3,00
I OV kHFLOW Sr.E'PAGE PI7 DRA.iNFIELD
EYTN..,CE POOL,DRY WFLL,MA NHOI_E; $3.00
_ ...-. r _-.
HOUSE ---- ---�...__ HNY,OR ST.WIDENING
' LTER.RE FAIR OR ABANDON.
SEVJER OR- SYSTEM $.3:00
_-___ _..- —___. s.-- S A.1'E ENCROAC HMENT "�".:
PERMIT NO.
INDUSTRIAL
' WASTE APPROVAL
OWNER'S PERMIT 2 i0
CHARGES
"- ^- - -------- `'-
r`— CONNECTION CHARGE FEE
TA
AUTHORIZATION TOL F'EE ,}. - --- -— --'- -- - — ---
'I ti AVE AT THIS DATE A CONTRACT WITH THE (HEREIN NAMED CON- REIMBURSEMENT FEE
TRAC Jft TO CONNECT THE ABOVE DESCR;BEO EXISTING DWELLING -- -p ---i-- - --- —' ---
TO THE 7BL.!C SEWER, y APPROVALSDATE )NSF-ECTOR S SIGNATURE
SIGNEDHI5 GAY OF 3''� 19---- -_..— ---- -----— -- --- -- _:__
OWNER OR ^'- ' NEW HOUSE SEWER
OWNERS AGENT. _
ONNECT ADDITIONAL
BUILDING OR WORK
ADGRESS ---------' ----
-.
£P71C,YANK.SEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRA9N.^IELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COJNTY ORDINANCES ANO STATE LAWS REGULATING I ;
PLUMeiNG AND SEWERS. CESSPOOL, ❑ DRYNELL ❑ fJi
I HERkF3Y C�"RT't RIFT++.A.7 I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSED AS REQUIRED BY" LOS ANGLES COUNTY-.AND STATE OF SEWAGE DISPOSAL SYSTEM �
T '['W
CA 1_IF'OR7JIA, OR TH ' I AM E LEGAL OWNER OF AND INTEND ND TO —'--_.. ___�
_ 1' DISCONNECT PLIJ C. AND 1
RESfDE IN-. THE DESCRIBED ftolf)EN AL/PROPERTY.
f. y - !' ABANDON HOUSE SEWER
SIGNATURE
OF PERM I T7 _ ._, • Ls „__-. BACKFII L SEPTIC TANKS L
T
-- -- SEEP,PIS) [J CESSPOOLS [}�
VALIDATION ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER h1.O. �J CASHSUPERVISING
I
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