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8A(514�0 APPLICATION FOR PERMIT
i.:
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL '
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION FADDRESS
JOHN A. LAMBIE, County Engineer ✓ ' 'r -'
WILLIAM A. JENSEN, Sup't of Luifdmq K
YFOR APPLICANT TO FILL INsr
DESCR FTICJN LOT NO OWNER
MAIL
BLOCK TRACT �J y/ ,,.. ADDRE:S �.,.:' l am_. y`
NO OF SLOGS, e
SIZE OF LOT P40W ON LOT CITY } !FL. NO.
USE C
BUILBIN S DISTRI -T NO. GRO, MAP PRO ESSED BY
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CONTRACTOR
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ADDRESS � ,` r - CONNECTION .DATA
✓ -a, ,,'� STATION
CITY. (` / -,:-TEL. NO_,�T.. r �' w' DEPTH Z •";%_-'j" --r+.; --_
`� ""7E MANHOLE.REFERENCE r i t IIPPSR
REGISTRATION NO. r") � - LJ COUNTY
-N-0.7--DESCRIPTION OF WORKFEE TYPE
-- ----TYPE OF-- ------'--6`:----`Cil ,�
I _ __ _ TYPE OF CONhECitCN.- - iENGTH FROM ^
HOUSE SEWER CONNECTING TO - -,f Y. CURB P L.;' M.L.TO P.L,
d PU£3L C SEW_R __-- �_Q
.... w� t. PC.NO ✓ a.,
SEPT TANK,SEEPAGE PIT - `
i 1 CO. IMP.NO.
PIT,AND/-OR DRAINFIELD $10.00 _
H u'EE-5-EWER CO-NNECTING TO TRUNK PERM17 NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM $3,00� I,
_r_f NNEC7 1D01^ION.AL HLOIU_OP. --- -----___.�--.
T AF(•-IDAY17 lv atv ERI raSEMEHT I. RECORD.IN$TR.NO DAT@ �6
WORK TO HOUSE SEWER $3.00
!EX N.,CESSt C':OL,DRYWELL.MANHOLE @ $5.00
-'ALTER,REPAIR OR ABANDON HOUSE
J�— HWY. OR ST.WIDENING �
SEWER OR DISP OS AL,YSTF_M $3_00 --r-
I _
.______...-._.—._ ��.__�._{. STATE ENCROACHMENT
I PERMIT NO.
1
INDUSTRIAL
j.! WASTE APPROVAL
OWNERERMI �
S PI —--- $ ' ---_—_— _---__..-------_ACRO—_
--+'—'—i-- CHARGES
_ _ _ oa
.^•F CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE ------- ----------.---- --- CARO
REIMBURSEMENT FEE
'! HAVE. AT THIS DATE A CONTRACT WITH THE HEREIN Nl(MED CON. ----------
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING --- TTff t7 c ------1--------------------
TO THE PUBLIC SEWER .f y APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS nAY BJP '` -- -- ts ---------- -- ---t - ---
fJWNEROR / )t
T �' "-- NEW HOUSE SEWER
OWNERS.AGEN
-'�' —"^i'-3'--` -- CONNECT ADDITIONAL
BUILDING OR WORK f
ADORES _- -.•�_:_ _.._ —ate --- --.-- ._t-�-.. --
_—
SEPTIC TANK.SEEP FIT(S)
I H R BY AC KNOWLEDGE. THAT I HAVE'. READ TH!5 APPLICATION AND/OR DRAIN.FIELD �
ANDTAIL- THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUN_,Y ORDINANCES AND STATE LAWS REGULATING I I
FLU.MEING AND SEWERS. CESSPOOL ORYWE.LL
HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND'OR ALTER,REPAIR,5LW£R OR --- ------ —`--- -----
LICENSED AS REQUIRE 0 BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM i
CALIFCRNI.4 OR THAT I AM THE LEGAL OWNER OF, AND INTEND TODIS-C6NN C1' -ILUG AND
RESIDE IN, Y!� ,_A L'J,;,E D CF'!5E0 RESIDENTIALi?RCIPERTY. pBAN DON HDU,E 'EWER f
l
SIGNATURE
BACKFILL SEPTIC.TANKS rl
OF FEr'eM LTTE£ _ �.s.:r—ls...._.__. SE_P.P! IS) i.�I `SPPOJLS EliI.
'VALIDATION ROBERT A. WOOD
r%y
C:KM.O. CASH SUPERVISING MECHANICAL ENGINEER
.