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6AS42D APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION
Ire 4�"
JOHN A. LAMBIE. County Engineer ADORES
WILLIAM A, JENSEN, Sup't of Build-ing,
LOCALITY
FOR APPLICANT TO FILL IN CROSS ST
DESCRIPT7 C;PS OWNTE
I-OT NO.
MAIL
"TR 461 ADDRESS___
NO, OFBLD GS.
SIZE 05 t-OT NOW 0NLOT CITY TEL. NO.
USE or DISTRICT NO, GROUP MAP POCESSED BY
BK PG
_-CONTRA CTOR
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A D D R FSS, CONNECTION DATA
'
CITY��4,F1' NO_ "AT3ON DEPTH
J-
• Y t- STATE UPPER
MANHOLE REFERENCE
REG15TRATIQN N-. 1' 1��------ -------------
_NO. I CESCRFPTION OF WORK ' FEE TYPE:OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING,70
YP.L. M.L.TO P.L.
@ >
%r.00 P,C.NO,
SEWER
--N!'- - P--6
SEPTIC fA K,SEEPAGE IT R JOB NO.
FITS AND/OR DRAINFIELDSEWER CON ,
--d
-41ZC�NG-T6- TRUNK PERMIT NO. ROAD PERMIT NO.
I TINGI
PRIVATE D!SPOSAL SYSTEM @ $3.00
RECORD.INSTPNo. DATE
WOR��TO HOUSE SEWER, $3.00
OVERFLOW SEEPAGE PiT,DRAjNF;ELD
"XIN,CESSFM�00L,DRYWELL, ANHOLL E Y .00
HWY.OR ST.WIDENING
ABANDON H 0 U S E
DISPOSAL SYSTEM
@ $ 0o
STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL,
WASTE APPROVAL
OWNER'S PERMIT 11-0 0
AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEE
r ----------
I HAV E A CONTRACT WITH THE HEREIN NAMED CON- IMMtIURMS� E�IT FEE
E AT THIS DAT _ _ _
TRACTOR TO CONNECT TH ABOVE DESCRIBED EX1571NG DWELLING
TO THE PUBLIC APPROVALS
SIGNED THIS DAY 0 F "4104 'o
OWNER OR EW HOUSE SEWER
OWNERS AGE CZ4
CONNECT ADDITIONAL
BUILDING OR WORK
SEPTIC TANK,SEEP-PIT(S)
IHEREBY AC WLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAIN-FIELD
T
AND STATE T}iACT`THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH'H ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMB ING AND SEWERS.
Rs. CESSPOOL Fj ORYWFLL D,
HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR Al-TER.REPAIR.SEWER OR
L;CE 0 AS R QUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM NSE D
-OR I LEGAL
E G I lr��ND TO
ALIr NIA OR HAT I AM rHE LEGAL OWN- OF, SCONNFCT PLUG AND
RESIDE _CR'T" 'T
DESCRIBED
R
N, THE BOVE. DES RE S" T L 0 ABANDON HOUSE SEWER
SIGNATURE
BACKFILL SEPTIC TANKS
SEEP.PIT
('�) CE55POCLS
VALIDATION ROBERT A. WOOD
SUPERViSING MECHANiC'AL ENGINEER
CK. M.O. CASH