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S&E-663 11.55 APPLICATIONFOR PERMIT
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DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Department of County Engineer
County Of LOS Angeles BUILDING
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS
® CASSATT D. GRIFFIN, SUPT OF BUILDING LOCALITY
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL OWNER
DESCRIPTION LOT NO.
MAIL
BLOCK TRACT ADDRESS
N0. OF BLDGS. CITY �' TEL. N0.
SIZE OF LOT NOW ON LOT
USE OF
BUILDINGS DISTRICT NO. GROUP MAP
BK PG
CONTRACTOR
CONNECTION DATA
ADDRESS
STATION _ DEPTH
CITY TEL. N0. �r//'' r���e� MANHOLE REFERENCE UPPER
REGISTRATION NO. ' 16,30 � ❑ COU TY - _ LOWER
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO TYPE OF CONN TION LENGTH F M
Y_ CURB P,L. M.L. T-0-P.L.
PUBLIC SEWER @ $3.50
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ $3.00 -
OVERFLOW SEEPAGE VIT,0RAtMP'tEt5- C. NO. _
EyTr. rpcSPOOL DRv�'�c� �.a _ @ $2.00CO. IMP. NO. 106 NO. -
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM @ $1.00 TRUNK PERMIT NO. OAD PERMIT NO.
CONNECT ADDITIONAL BLDG.OR STATE ENCROACHM T.
WORK TO HOUSE SEWER @ $1.00 PERMIT NO. - --
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL -
SEWER OR DISPOSAL SYSTEM @ $1.00 WASTE APPROVAL
CHARGES
CONNECTION CHARGE-FEE
- -
OWNER'S PERMIT $ 1 00
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- -APPROVALS DATE INSPECTOR'S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. NEW HOUSE SEWER
SIGNED THIS DAY OF 19 CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK _�--••'�'�
OWNERS AGENT SEPTIC TANK,SEEP,PI S)
ADDRESS AND/OR DRAI -^✓ti.
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL❑ DRYW ELL❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
IHEREBY CERTIFY THAT l AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HO PLUGUSE D
CALIFORNIA OR THAT I AM THE LE AL OWNER OF THE ABOVE
ER
DESCRIBED RESIDENT A 6OPERT t BACKFILL SEPTIC TANKS❑
SIGNATURE SEEP. PIT(s) Q CESS POO LS❑
OF PERMITTEE
JOHN A. LAMBIE, COUNTY ENGINEER VALIDATION ROBERT A. WOOD, CHIEF PLBG. INSPECTOR
10
,
. ✓L.ilti.� ®ppb
ceeoe•e•se CO NTY OF LOS ANGELES ®�
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS
JOHN A. LAMBIE, County Engineer
CASSATT D. GRIFFIN, Supt of Building LOCALITY OV
NEAREST
FOR APPLICANT TO FII1 IN CROs ST.
LEGAL
DESCRIPTION LOT NO., OWNER
G
BLOCK T C % MAIL
f ADDRESS
'A Xog
0.OF BLDGS.
SIZE OF LOT ` N LOT CITY (-IV,.N0.
USE OF
' BUILDINGS DISTRICT N0. GROUPI MAP ROCESSED BY
jHK PG
CONTRACTOR'
}
ADDRESS CONNECTION DATA
CITYL.N0. STATION,,-?, 74-S C2 EPTH 7
//! S ATE MANHOLE REFERENCE UPPE
REGISTRATION NO. / ( �'�" L OUNTY 5 WER
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3.00 TYPE OF CO ECTION LENGTH FROM %
SEPTIC TANK,SEEPAGE PIT OR Y. CURB P M.L.TO P.L.ITS AND/OR DRAINFIELD @ $3.00 _
OVERFLOW SEEPAGE PIT, DRAINFIELD '
EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $2.00 '
HOUSE SEWER CONNECTING TO P.C.NO.
PRIVATE DISPOSAL SYSTEM @ $1.00 CO.IMP.NO. QO JOB NO.
CONNECT ADDITIONAL BLDG.OR
WORK TO HOUSE SEWER @ $1.00 TRUNK PERMIT N0. ROAD PERMIT N0.
ALTER, REPAIR OR ABANDON HOUSE @ $1 00 STATE ENCROACHMENT
SEWER OR DISPOSAL SYSTEM PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERBUT $ 2 00 CONNECTION CHARGE FEE
" AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. RPPROVALS DATE INSPECTOR S s1GNATURE
TRACTOR TO CONNECT THE.ABOVE DESCRIBED EXISTIN DWELLING
TO THE PUBLIC SE R.
SIGNED THIS AY OF 19 NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
SEPTIC TANK,SEEP, PITS)
ADDRESS AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THA HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL❑ DRYWELL❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER, REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE.DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES CO TY AND STATE F ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM THE LEGA 0 E OF THE AB j
DESCRIBED RESIDENTIAL PROPERTY. SEEP.BACKFILLPIT(S)P(]C TANKS CESSPOOLS❑
SIGNATURE
OF PERMITTE ;ry,:..a.,...+;.3.d`
®E VALIDATION ROBERT A.WOOD
g, m,p, gAgg SUPERVISING MECHANICAL ENGINEER
LE05657 Fti ! 1 0 A 5.00 *