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PLICATION FOR PERMIT 1
•84eODIIIISION OF BUIMING AND SAFETY SEWER-SEWAGE DISPOSAL
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JOHN A. LAMBIE, COUNTY ENGINEERm CASSATT b. GRIFFIN, SUPT OF-BUILDINO ITY
FOR APPLICANT TO FELL IN R ST.
LEGAL OWNER
DESCRIPTION LOT NO.
PAIL
BLOCK TRACT ADDRESS
,*-aoi OF BLDGS. CITY L. XO.
SIZE OF-Lb (J (JX 01.ON LOT
USS DI DISTRICT XO. GROUP MAY `
BUILDINGS
BK Po '
CONTRACTOR
CO ON DATA
A_DDRESS
r
S'� STATION DEPTH
CITY . M0. MANHOLE R X E UPPER
�,1ATE LOWER
REGISTRATION N0. ❑ COUNTY
Mo. DESCRIPTION OF WORK FEF
HOUSEBEWER CONNECTING TO TYPE OF CONNECTION M.L. TO FROM
Y. CURB F.L. Y.L.TO P.L.
PUBLIC(EWER
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ S 3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD CO. IVP. N0. ]OB N
EXTN.,CESSPOOL,DRYWELL MANHOLE 2.00
HOUSE SEVER CONNECTING TO
PRIVATE DISPOSAL SYSTEM Q s 1.00 TRUNK PERMIT X0. ROAD PERMIT NO.
CONNECT ADDITIONAL BLDG.OR .� STATE EXCROACHME
WORK TO HOUSE SEWER ® !1.00 PERMIT X0.
ALTER,REPAIR ORABANDON HOUSE INDUSTRIAL
SEVER OR DIS SAL SYSTEM @ 1.00 WASTE A AL -
CHARGED
CONNECTION CHARGE FEE
OWNER'S PERMT ; Do
AUTHORIZATION TOTAL FEE REIYBURSEYElIT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- APPROVALS DATE INSPECTOR'SfIGXATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED ¢ISTING DWELLING
TO THE PUBLIC SEWER. NEW HOUSE SEWER. _
SIGNED THIS SAY OF 19 CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK S�
OWNERS AGENT SEPTIC TANK,BEEP,PIT(3)
ADDRES* AND/OR DRANIFIELD
1 HEREBY ACKNOWLEDGETHAT I HAVE READ THIS APPLICATION CESSPOOLQ DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AY PRObERLY REGISTERED ANb/OR
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCO XNECTPLUG AND
CALIFORNIA OR THAT I AY THE LEGAL OWNER OF T E ABOVE ABANDON HOUSE SEWER
DESCRIBED RESIDENT ROPERTY. BEEPFPIT S5❑ TANKS
❑LS❑
SIGNATURE ,
OF PERMITTE -
JOHN A. LAMBIE, COUNTY ENGINEER VALIDATION ROBERT A.WOOD, CHIEF PuBa. INBPECTOR
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