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7AB42D APPLICATION FOR PERMIT _� 1
8
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS _. � �r„' I jl=•
IOFIN A. LAMBIE, County Engin"r — 4
WILLIAM A. JENSEN. Supt o1 Building LOCALITY 2< i.3'
NEAREST
FOR APPLICANT TO FILL INcROs-5 ST.
DESCRILEGPTION LOT NO, hr OWNER
BLOCK TRACTt MAIL
J ADDRESSi' -'S.. .. -
N0.OF BLDGS. 7 .,
SIZE OF LOT NOW ON LOT CITY w «z s TEL. NO
USE OF 4
BUILDINGS CJlp :'Y -- .=� 4a. .DISTRICT NO. GROUP MAP PROCESSED BY
BK PG '
CONTRACTOR 3 I�' ✓ �r %:� % �_ _
ADDRESS ✓� CONNECTION DATA
CITY g TEL.NO,;f/ STATION DEPTH s'
J STATE MANHOLE REFERENCE 3'
NO. r
19 LOWER
NO. DESCRIPT[ON OF WOPK TRATICOUNT
ON
F0
t"E S N ER CONNECTING TO
PUBLIC SEWER $3.00 ? TYPE OF OOf1PiECTION LENGTH FROM
SEPTIC TANK.,SEEPAGE PIT OR Y. /CURB..' P.L. M.L.TO P.L.
PITS AND/OR DRAINFIELD C.a $3.00 _
jOVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN,.CESSPOOL. DRYWELL @ $2.00
HOUSE SEWER CONNECTING TOP.C,N0,
PRIVATE DISPOSAL SYSTEM @ $1.00 CO.IMP. NO. .,� JOS N0.
s 0
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT N0. ROAD PERMIT N0. r
WORK 70 HOUSE SEWER @ $1.00 _ ���'''
A!_TFR,REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
SEV,'El2.OR Di,PORAL 5Y.5'IEM C� $t:OO PERMIT N6, O�r
INDUSTRIAL - U
- - WASTE APPROVAL a
CHARGESOWNER'S PERMIT s 2 OO CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE I - - � REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON=
TRACTOR TO CONNECT THE AS OYE DE RIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWE,R,.
SIGNED THIS�DAY OF Lam_ —19 , NEW HOUSE SEWER
OWNER OR ;i °°, - ., CONNECT ADDITIONAL
OWNERS AGENT - BUILDING OR WORK
ADDRE55 .� �+- f „s,�„'' SEPTIC TANK,SEEP.PITS?
AND/ORDRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL CI DRYWELL []
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
:PLUMBING AND SEWERS' SEWAGE DISPOSAL SYSTEM
I HF?EBY CERTIFY T I AM PRO..I' RLY ISTERED AND/OR DISCONNECT PLUG AI9D
LICENSED AS REOUIR^ ,".BY LOS A LE C NTY AN STAT OF
ABANDON HOUSE SEWER
CALIFORNIA OR TH I AM THE•'LEGA 0 NER THE OVE -
DESCRIBED RESIDEfi I, PROPERIYI_ SACKF LL SEPTIC TANKS (]
SEEP.PITS i=k CESSPOOL$
SIGNATURE
OF PERMI
5F /V ATIONl -" RO ER'r A. WOOD
M.o. CASH SUPERVISING MECHANICAL ENGINEER
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