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76A 642D APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS r
COLEMAN W. JENKINS. SUPT. OF BUILDING
LOCALITY
F NEAREST
R APPLICANT TO FILL IN CROS ST.
(PRhNT OR TYPE ONLY)
LOT NO OWNER
MAIL
BLOCK TRACT b 11 Z, /
ADDRESS
NO, OF OLD G5.
7'
SIZE OF LOT NOW ON LOT CITY TEL. NO.
D�Z-
ES
K
DESCRIPTION
P
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LOCALITY
BUILDINGS
BUILDINGS LISTRICTNO.1 GROUP CLASS MAP PR0CES5EG 9Y
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RA_T_
CONTRACTOR
ADDRESS
CONNECTION DATA
CSTATION DEPTH
TEL, NO.
CITY
STATE E'
LIC MANHOLE REFERENCE --UPPER
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-----
LICENSE NO CLASS • 2
- LOWERN
TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER Y. CURB P.L. M.L.TO P.L.
SEPTIC TANK,SEEPAGE PET OR___- __$5_00P.C.NO.
PiTS AND"OR DRAINFIELD @ $1000 CO !MP.N JOB NO.
--1HO USf SEWER C ONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO,
,_PI1IVATE DSPOSAI 5YSTEM S3,00
ONNECf�6OjTj-ejj- 'R A F_F(DAV I T winvT�- t—NT-11—REC-COR-D---�IN—STR---NO. OAVE
La
C , 4;-BLDG.
WORK TO HOUSE SEWER $3:00
ovERFLow SEEPAGE PIT,DRAINFIELD ----
EXTN CESSPOOL DRYWELL.MANHOLF $5,00 I
HW OR S7 AL T E R SE - --- 0
SEWER 61q`rr5P`O9*"1vQZ" @ $3.00
------ STATE ROACH
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL 4m
ou z
r
CIAR.
OWNER'S PERMIT $ 00
I CONNECTION CHARGE FEE
AUTHORIZATION TOTAL ME -----
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-- REIMBURSEMENT FEE
TRACTOR
ACTOR T CONNECT THE AaOVr DESCRIBED EXISTING DWELLING
T 0 PUBLIC CON APPROVAL-S-T
THE UBLIC SEWER. DATE INSPECTOR'S SIGNATURE
SIGNED THIS-----DAY -------
OWNER OR NEW HOUSE SEWER
OWNERS
CONNECT ADDITIO N AL
G O
BUILDINR WORK
HEREBY ACKNOWL.EOGr THAT I SEPTIC TANK,SEEP,PIT(S)
I
HAVE READ THIS APPLICATION AND�ORDRAINFIELD
AND SrATE TH4T THE ABOVE - CORRECT AND AGREE TO COMPLY
W IT, A I-- COU NTY ORDINANCES AND STATE LAWS REGULATING
O
PL_(,;Mal NG AND SEW E Rs. -CE5x1.P?.1, DRYWEL.L
HEREBY �FPTIFY THAT ( AM PROPEPNY RFG�,PTERED AND/OR -LnER-RWCPAIR.SEWER OR
LliC Z:NSED AS REQUiR ED LOS ANGLES COUNT AND STATE OF SYSTEM
C ; I THE: LEGAL OWNER 0 , AN :'INTEND TO
,A'- FORN A OR THAT I AM ---- ]� --- I
R E:5 I OL !N, THE ABOVE DIES, DISCONNECT PLUG LUG AN
,ppl VF RE P 0 RTY� ABANDON SE SEWER
�
SIGNATURE
OF E
FF RMTTTFE BACKFILL SEPTIC TANKS 10 1
I
SEEP,PIT(S)_E1 CESSPOOLS 0!
VALIDATION JACK R. ALLEN
M.0. CASH SUPERVISING MECHANICAL ENGINEER
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