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24690 INSERTS �
6Dco APPLICATION FOR PERMIT
A�4" COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING
BUILDING AND SAFETY DIVISION ADDRESS
.AMBINtongg1I&LAMAIENSSup uxdnt LOCALITY
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NEAREST
FOR Opp ANT - , FILL
LEGAL � - i._ ', OWNER.
DESCRIPTION LOTNO. -
BLOCK TRACT MAT1`
} ..^•. ADDRESS. •�'F. .a
NO.OF BLDGS_ - v
SIZE OF LOT NOW ON LOT CITY q / TEC.. NO.
Usr_OF ^� a '�: .s DISTRICT N0, GROUP MAP PROCESSED Sl(
BU'LDING3 �•� ,E:-L
BIC er.
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CONTRACTOR J..:�k1
ADDRESS
CONNECTION DATA,
CITY TFL.NO, E STATION , ' fs': DI _
STATE MANHOLE REFERENCE a - y LIP'P
REGISTRATION NO. s� - COUNTY� +� .^'_- /�e .�� �t,..s� ,r, OWER
NO. DESCRIPTION; OF WORK FEE �<
HOUSE:YErYER CONNECTING TO �.-,
PUBLIC SFVvER C' $3.00 _ TYPE OF..G CT'ON LENGTH FROM
SEPTIC TANK{ SEEPAGE PIT OR Y. ;-CURB^ P<L. M.L.TO P,L,
PITS AND/OR D'RAiNFIEL.D @ $3.00
iOVERFLOW SEEPAGE PiT, DRAINFIELD
EXTN..CESSPOOL. DRYWELL 0
HOUSE SEWER CONNEMING P.C.NO.
r PRIL{ATE DISPOSAL SYSTEMC? $i,00 CO, PMP. NO. `t`'`-, SOH NO. �
CONNECT ADDITIONAL BLDG.OR
. .'� .83.00 TP,UNK PERMIT NO. ROAD PERMIT
OPK.TO HOUSESEWER
ALTER,REPAIR OR ABAND^N HOUSE. STATE ENCROACHMENT
SE1^FI=R OR DISPOSAI.SYSTEM $1.00 PERMIT N0. 9
INDUSTRIAL. u
WASTE APPROVAL
CHARGES
OWNER'S PERMIT 2 100 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR
ON TRACTDR TO CONNECT THE ABOVE DEQ'RIBED 1STING DWELLING APPROVA J DATE INSPECTOR'S SIGNATURE
TO THE. PUBLIC SE y^ �
SIGNED THIS-----��` DA f OE• NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL T
OWN.,RSAGE'?vT.� .'.s^ -••"� �' '�'.. ^`" BUdLDiNGO:RWORK I
'kDDRE�S. SEPTIC TANK,SEEP.PIT(S)
ANA/OR DRAINFIELD
1 HERESY ACKNOWLEDGE THAT 1.HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE iS CORRE.CT AND AGREE TO COMPLY CESSPOOL [I DRYWELL Cl
WITH ALL, COUNTY ORDINANCES AND STATE LAWS REGULATING. ALTER REPAIR.SEWER OR
PLUMBING AND SEWERS. 1,�-"�` SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY TH.6T i AM PR. RLYr`6CEGISTEREO AND,0 DfSCONNct�T'PLUG APrU
LICENSED AS RCOUIRF ,$'Y LOS COUNTY AND STAFF ARAidOON HOUSF SFWER
CALScORNIA OR THAT„ ABS THEEGL DINER E AB
DESCRIBED D R DEN*. `PROPERTY. ` r°" ��"' r' BACKFILL SEPTIC TANKS El
SIGNATURE SEEP.NIT(S) G CESSPOOLS []
OF PERMITe ' __
p DATION+ ROBERT A. WOOD
7pd SUPERVISING.MECHANICAL Ei�GINEER.
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