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75AS42D642D 82 APPLICATION FOR PERMIT �
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIEo County Engineer ADDRESS r i � ��.
WILLIAM A. rEN5EI1, up`t of Building ------
LOCA-ITY
N4REST --
FOR APPLICANT TO FILL IN GR055 ST
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AL
DESCRIPTION LOT NO- OWNER
BLOCKTRACT '� �rrY ADDS J
-- - --- -
NO. OF BLD�GS. .. I
SIZE OF LOT NOW ON LOT' CITY 'TEL. NO.
USE OF
BUILDINGS DISTRICT NO. OUP A1AP PROCESSED BY
PG
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CONTRACTOR _— -_�— Y, .�. V � f'�' {° .•
AODRFSS ,y CONNECTION DATA
4
daz''-r- p STATION - --__DEPTH
l'IT'Y /J 1 TEL NO. �r �i
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STATE UPPER
REC!3 fxATiON NO ,�pl} �gp ', k - COUNTY MANHOLE REFERENCE. - LOWER }�
V
NO. I DESCR PTION OF WORK: FEE TYPE OF CONNECTION - �."L`c'N, H FROM
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- —__. -..
_� HOUvE S._WER CONNECTING'O -� �— _.__ Y. CtJ RB P.L. M.L,TQ P.L. t.J
PUBLICSEW-ER $5.00 — -.___— T __-
.-- - P.C.N0 �
PITS IG TANK,SEEPAGE PIT' OR JOB NO
!TS AND OR DRAINF_FLO $90.00 CO.IMP NO. O
P 1- _
A
HOUSE SEWER CONN Crl NG-1 -__....�.�___....� \
PRIVATE - SYSTEMSYSTEM @ $$.00 7Rt1NK.PERMIT NO. ROAD PERMIT NO.
_— ---_ —__ -_--_. __—_ _
p;, O INr A).J11;ONA Bi_DG OR �I AFF16A4 T wRIMFN cns'€ME x -{ECOID INSTF NO. DATE
IN JR} Y:J HOUGE&E�NEF3 7 $3.0(j { �—
OVERFLOW SLI"'At k PIT.DRA!NFIELD - 1 7�a P
XTN.,CES.EPOOl,DRYWEI.LIMA NH OLE $5.00 — t ✓ .;5 -
ALTER,REPAIR OR ABANDON HOUSE OR 5T.WIDENING
EWER OR 1'PO+•AL 5`+STE M. ---`--
.. 5.00 � STATE ENCROACNM ENT
PERMIT NO.
INDU$TRIAL _.
I WASTE APPROVAL
t __— CHARGES -"
OWNF ws PERMIT 21 00 -- --- - - -T -
- -
CONNECTION CHARGE FETE
A'Lt"TI�OZATION TOTAL- FSE---
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I HAVE A' -HIS U4TFA CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT F
TRACTOR
TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING - " --*--- ------ -
TO THE FURLIC SEWER. APPROYALw7 DATE i NSPECTOR'S SIG
NATt:RE
SIGNED --
'Y!-ii5____ DAY -
OWNER OR NEW HOUSE SEWER
OWNERS AGENT—---- CONNECTADDITIONAL
BUILDING Oh.:WIGR
ADDRESS
H SEPTIC TANK,SEEP PIT{S}
I HFR BY -ACKNOWLEDGE THAT f HAVE REAP TNI a APPLICATION AND
DRAiNFIELD
AND STATE THAT 'THE ABOVE !S CORRECT AND AGREE TO COMPLY
Wi'fH ALL COUNTY ORDINANCES AND 5TATE LAWS REGULATING i
PLUMS
ING AND 5EW'E RS. CESSPOOL ❑ DRYWELL
I HEREBY CERTIFY THAT { AM' PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR i
LICENSED AS REQWRF;O eY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABOVE DESCR!'BED RESIDE TIAL PROPERTY. ABANDON HOUSE SEVER
SIGNATURE / .gr HA KFILL EPTICTAN SSS F]
OF PERMl7'TEEe C,1 CF.SSPOOL: [J'
VALIDATION ROBERT A. WOOD
r
SUPERVISING MECHANICAL ENGINEER
M.o_ CASH