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76A6421) APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING �x
JOHN A. LAMBIE, County Engineer ADDRESS — E � y /` `
WILLIAM A. JENSEN, Sup't of Building (�
LOCALITY
NEAREST _ _—___
FOR APPLICANT TO FILL IN
CROSS 5T.
-- - - -- -
LEGAL __- `�`�'-�.�` _ —_—._—____ ,..+,
DESCRIPTION LOT NO ---� - '�
OWNER s � ..kT= w( _
.,r MAIL _
BLOCK ---- TRACT y y,,' ADDRESS '"
NO. OF BLbGS. j
SIZE OF LOT NOW ON LOT CITY - - in`�;'_;ZZ EL. NO.
USE OF _-- -- �
BUILDINGS _ DISTRICT NO. GROUP MAP PROCESSED BY
BK PG
r ✓ :_
CONTRACTOR P' y - n� j_�_� l^ `�
ADDRESS ?f / CONNECTION DRTA
`a. STATION
-L NO. ; _ -� ,r DEPTH ._
r- ST'ATE p r-------- .✓ '^ UPPER
MANHOLE REFERENCE ;l 1
REGISTRATION NO. i� �y LJ COUNTY `'..� ,f -{aFsy Vw_
NO, DESCRIPTION OF WORK FEE i TYPE OF CONNECTION , LENGTH FROM
HOUSE SEWER CONNECTi NG TO I Y. CURB
PUBLIC SEWER - $5.00
§ FS L. M.L. C6 P.L.
;5 r
_ _00
SEPTIC TANK,SEEPAGE PIT OR -- P.C.NO,
.ITS AND/OR DRAINFIEL..D @ $10.000 CO.IM.P.NO, JOB NO
p
! HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM $3.00 -
CONNECT ADDITIONAL BLDG OR AFFIDAVIY 4WAIVER EASEMENT RECORD, INSTR NO,. I DATE
_61E
ORK TWO HOUSE SEWER $_3.00
OVERFLOSEEPAGE FIY DRAINFIELD -��
E.TN.,CEFSPOO L,URY WELL,M'NHOLE $5.00 1j
ALTER,REPAIR OR ABANDON HOUSE
HWY.OR ST.WIDENING C.
SEWER OR DISPOSAL SYSTEM $33.00 STATE ENCROACHMENT V)
— PERMIT N.O. z
1 INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNER'S PERMIT �s 2 00 --
�.,� CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE
�I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT.THE ABOVE DESCRIBED EXISTING DWELLfNG
TO THE PUBLIC S.EW -- APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS �. DAY OF IC L I
OWNER OR NEW HOUSE SEWER -
OWNERS AGENT 4� CONNECT ADDITIONAL ,fes
BUILDING OR WORK
ADDRESSr. r y'd
- ._.- _..
SEPTIC TANK,SEEP,PIT(S)
IH
A-KNOW LEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFLELD �
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES. AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑ Ili(
1 HEREBY CERTIFY
THAT E AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR I
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABOVE DESCRIBED RPROPERTY ABANDON HOUSE FEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMITTEE _ _ - "rr SEEP,PIT(S) El CESSPOOLS ❑
VALIDATION ROBERT A, WOOD
SUPERVISING MECHANICAL ENGINEER
CK. M.O. CASH