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CE808 1f-57 APPLICAT[ON FOR MIT
E808 COUNTY OF LOS ANGELES SEWER-SEWAG
WWA DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION JADDRESS
ILDING
JOHN A. LAMBIE, Count Engineer 77CASSATT D. GRIFFIN, Supt of Building � " /�CALITY ,o a-d/y- , �"I
AREST
FOR APPLICANT T9 FILL IN CROSS ST:-
LEGAL S
DESCRIPTION LOT NO. OWNER U
MAIL
BLOCK ' TRACT /r �-. y$ "9 A DRESS I 'j c-.a
y G .NO. OF BLDGS. /
SIZE OF LOT y O NO. ON LOT CITY Gd.�K �H®i2 ,."t�J..9__,TEL. NO,
USE OF .� _ .. - ..
BUILDINGS '°`'.n a 1-� % 1 e �..'z. DISTRICT N0. I GROUP .1 MAP
CONTRACTOR
� g P7
ADDRESS A CONNECTION DATA
J
CITY .."i�.� ,.I!p_ .e4 TEL.NO. 1_11!4/ ^ LSTATION flEPTH
-AlF STATE MANHOLE REFERENCE
REGISTRATION NO. p' f y � COUNTY
NO. DESCRIPTION OF WORK FEE LONE
HOUSE SEWER CONNECTING TO
1 PUBLIC SEWER @ $3.50 - TYPE OF CONNECTION LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR Y. CURB .L. _ M.L.TO P.L.
PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXT N.,CESSPOOL,DRYWELL,MANHOLE @ $2.00
HOUSE SEWER CONNECTING TOP.P.C.NO.
PRIVATE DISPOSAL SYSTEM @ $1..00 4 CO.IMP.No 6&7z7'2 JOB NO.
CONNECT ADDITIONAL BLDG.OR
L' WORK TO HOUSE SEWER @ $1.00Too
TRUNK PERMIT NO: ROAD PERMIT N0.
ALTER,REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM @ $1.00STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNER'S PERMITt.
$ CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
I HAVE AT THIS DATE A. CONTRACT WITH THE HEREIN NAMED CON -
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS DAY OF 1 g_ NE w HOUSE SEWER
OWNER OR __ .. _. CONNECT ADDITIONAL - - - ---• -•
OWNERS AGENT BUILDING OR WORK
ADDRESS - --_ SEPTIC TANK,SEEP,PIT(S)AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION t
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL❑ DRYWELL❑
WITH ALL -COUNTY ORDMANCES `AND -STATE LAWS REGULATING
PLUMBING AND SEWER$: ALTER,REPAIR,SEWER OR
HEREBY CERTIFY 'THAT I AM PROPERLY*REGISTERED AND/OR SEWAGE.DISPOSAL SYSTEM _
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF THE ABOVE ABANDON HOUSE SEWER
DESCRIBED RESIDENTIAL-PROPERTY
- BACKFILL S-
SIGNATURE '✓ /r-y ,� a ° CESSPOOLS
OF PERMITTEE ' / ¢r✓
®r VALIDATION ROBERT A. WOOD
M.o. CASH SUPERVISING MECHANICAL ENGINEER