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76A6420 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER SEWER—SEWAGE DISPOSAL
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE Coun!y En &S199S ADDRESS
WILLIAM A. JENSE�. Supt of guilding
LOCAL
NEAREST
FOR APPLICANT TO FILL IN CROSS ST
DESCRIPTION LOT OWNER
ADDRESS r S�
L
A L'_
I
N EA REST
CR 0..
TRAC-T ADDRESS
NO OFBLDGS,
SIZE OF LOT NOW ON LOT CITY TEL, .4c,
USE OF
Elutul!N-s
NO. GROIJ] WAR, BY
X
CONTRACTOR
Aj
ADDPF JJ, CONNECTION DATA
STATION DaITH
TEL No
STATE:
MANHOLE REFERENCE
REG.STRATION NO ' COUNTY
LOWER
DESCRIPTION OF'-VVCFi3� F
TYPE OFCONNECTIONLEN TH FRC*.
HOUSE SFWERONNECTING TOY. CURB M.L.TO P.L,f
PUBLIC SEWER $5.00 4 _ P.C' 0
-to_
SEPTIC TANW,-SEEPAGE OfT -
.
PITS AND/'O-R DRAiNMELD �10.00 CO.IMPNO.
SEWFR CONNECTING To
PRIVATE ClS-OSAL,SYSTEM $3 00
TRUNK PERMIT NO. ROAD PERMIT NO.
-4-
CoN NECT ADDITiONAL BLDG OR WAIVER 1ASE-MENT --D 4—
A F F 16 A 11-1-T T IiE OR..li STR. NO, DATE
WOS K TO 14OUSE$EWER $3.00
OVERFLOW SEEPAGE.ilf�DPAHNFIELD --------
EXTNCESSPCOL,DRYWELL.MA4NHOLE @ $0.00
HWY.OR ST,WIDENING
ALI C R,RE AIR OR ABANDON
SEWER OR"DISPOSAI.SYSTEM —0
i-- STATE ENCROACHMENT
PERM) NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OlmRS PERMIT $ 00
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE ------
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN N A M E D C.0 N- REIMBURSEMENT FEE
T F?A C,OR To CONNECT THE ABOVE. DESCRIBED EXISTING DWELLING
I THE PUBLIC SEWER APPROVALS i DATE i NSPECTOR'S SIGNATURE
SIGNED THIS I
_____DAY OF'-- 9__
OWNER OR NEW HOUSE SEWER
CWt4ERS A Z:EN r ------
CONNECT ADDITIONAL
BUILDING OR
BU
Arlo E ILDWORK
__-- ' S a-- _—.-- ----- -- .--- —4—
SEPTIC TANK,SEEP'PITS)
"IrRf BY ACKNOWLEDGr THAT I HAVF READ THIS APPL ICAl!ON AND/OR DRAINF
A N D STATE THAT THE AS 0 VP IS CORRECT AND AGREE TO COMPLY I-E L-D
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATiNc
PLUMBING AND SEWER�. CESSPOOL. ORYWELL
1 HER BY CERTIFY ";-TAT I AM PROPERLY REGISTERED AND1GR ALTER,REPAIR.SEWER OR
F 'LES
c.NSED AS REQUfREV BY LOS AN��, COUNTY AND STATE. OF SEWAGE DISPOSAL SYSTEM
_OR -M -f
Ir A OR THAI I A, HE LEGAL OWNER OF, AND INTEND 1-0 j,7,N
iE ABOyf PESt�RJBED RE��JDENTiAl PLUG AND
RE:,Slt-E lNl I-i� PROPERTY. ABANDON.HOUSESEWER
SIG RE
RMIT I
OF PEI SACKFILLSEPTiC7ANK5 'Ll
------ SEEP,PIT(S) CESSPOOLS 0i
VALIDATION ROBERT A. WOOD
CASH SUPERVISINGMECHAWCAL ENGINEER