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�E0APpLIcATION FOR PERMIT
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COUNTY OF LOS ANGELES SEWER SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING .
JOHN A. LAMBIE, County Engineer ADDRESS
CASSATT D. GHIFFIN< Sup't of Building mac" t
OCALITY,
L
NEAREST
FOR APPLICANT TO FILL IN CROSS ST. "
LEGAL
DESCRIPTION LOT NO. -7✓ `y OWNER
BLOCK TRACTMAIL r
, l ADDRESS
-7N0.OF BLDGS, ,yf
SIZE OF LOT � :, Y:,, '' NOW ON LO7 CITY -`+' '7.-°:�' i. N0. -"
USE OF Res DISTRICT NO. GROUP MAP PROCESSED BY
BUILDINGS
g, BK PG
CONTRACTOR
Able
p ryry _ l r
ADDRESS 225 W bT'yant Rd. CONNECTION DATA
CITY El TEL.N0. STATION DEPTH t _-
�y [�-6565
STATE MANHOLE REFERENCE UPPER
REGISTRATION NO. 168579 ❑ COUNTY
NO, DESCRIPTION OF WORK FEE t"r LD44ER
HOUSE SEWER CONNECTING TO
PUBLIC SEWER $3.00 r TYPE OF CONNECTION LENGTH FROM
SEPTIC TANK.SEEPAGE PIT OR Y. CURB P.L.^~ M:,L.TO P.L.
PITSAND/ORDRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT,GRAINFIELD _
EXTPn,CESSPOOL.DRYWELL $2.00
HOUSE SEWER CONNECTING TO - - P.C.NO.
PRIVATE DISPOSAL SYSTEM @ $1.00 CO.IMP, NO. �• SOB NO,
CONNECT ADDITIONAL BLDG,OR - TRUNK PERMIT NO. ROAD PERMIT NO.
WORK TOHOUSE SEWER $1,00
ALTER,REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
SEWER OR DISPOSAL SYSTEM @ $1.00 PERMIT NO,
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT Z OO CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE I ti. c" � REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER. �i -
SIGNED THIS DAY OF 9S� NEW HOUSE SEWER
OWNER ` CONNECT ADDITIONAL
OWNERSAGENT
AGENT ®3," 8UILDiNG OR WORK
ADDRESS_ SEPTIC TANK,SEEP.PITS)
AND/ORDRAINFIELD
I HEREBY ACKNOWLEDGE THAT IHAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL (]
WITH ALL COUNTYORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. ALTER,RESEWER OR
PAIR,
I HEREBY CERTIFY THAT I .AM PROPERLY REGISTERED AND/OR SEWAGEPAIR,DISPOSALSYSTEM
DISCONNECT PLUG
LICENSEDAND
AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SAND
CALIFORNIA OR THAT I AWS THE LEGAL OWNER OF THE A VE — —
DESCRIBED RES t PRQRRTY. .; «� BACKFILL SEPTIC TANKS I]
SEEP.PIT(S) C] CESSPOOLS n
SIGNATURE ✓ -.- a y' -
OF PER.MIT'I' .... ..' '
ALIDATION ROBERT A. WOOD
Ctc. S.Q. CASH SUPERVISING MECHANICAL ENGINEER