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EBOS 3-152
6A6420 APPLICATION FOR PERMIT Y
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
FADDRESS yx-
JOHN A. LAMBIE, COUNTY ENGINEER
COLEMAN W. JENKINS, SUPT. OF BUILDING
LOCALITY All
LOCALITY
___
NEAREST
CROs
ROSS ST-
FOR APPLICANT TO FML IN
LEGAL
DESCRIPTION LOT NO.- OWNERe:.7
MAIL
BLOCK TRACT ADDRESS
NO. OF EILDGS.
SIZE Or LOT NOW ON LOT CITY TEL. NO.
USE OF
1
BUILDINGS DISTRICT NO. GROUPMAP PROCESSED BY 1 B11 PrI
CONTRACTOR-
ADDRESS, CONNECTION DATA
TEL, N 0. STATION DEPTH
CITY
STATE r LIC MANHOLE REFERENCE
LICENSE NO r
_CLASS_,, LOWER
NO, j DESCRIPTION OF WORK FEE TYPE OF C�r'
tAJFCT I ON LENGTH FROM
HOUSE SEWER CONNECTING
TO Y. M.L.TO P-L.
PUBLIC SEWER @ $5.00
SEPTIC TANK,SEEPAGE PIT OR - P.G.NO.
Co. IMP.NO. JOB NO. u
PITS AND/OR DRAINFIELD $100-Gi—
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. Ed
0
PRIVATE DISPOSAL SYSTEM $3.00
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAVER I, CUT RECORD.INSTIR.NO. DATE
WORK $3.0 HOUSE SEWER to,
TO 0 u
__ _ I
OVERFLOW SEEPAGE PIT,DRAINFIELD CL
EXTN.,CESSPOOL.DRYWELL.MANHOLE SS.0.0 HWY. OR ST.WIDENING
- --------------- t--1IIJDOuse
ALTER, REPAIR OR z
SEWER OR_RISPOSAL SYSTEM @ $3,00
STATE ENCROACHMENT
i. PERMIT NO.
WASTE APPROVAL
CHARGES
OWNERS PERMIT $ 2 00
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE
IHAVE. AT THIS DATE A CONTRACT WITH THE HEREIN I NAMED CON- REIMBURSEMENT FEE
TRACTOR
RACT 0 R TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
DATE INSPECTOR'S I URE
_
TO THE P UBLIC SEWER. APPROVALS
SIGNED THIS.DAY OF 19
OWNER OR NEW HOUSE SEWER
OWNERS AGENT___
CONNECT ADDITIONAL
BUILDING OR WORK
ADORES S-._,__._�—�
SEPTIC TANK,SEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND
STATE THAT THE
E ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL D DRYWE:LLc_l
IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LIrENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CAL,FORK I A OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN. T H E ABOVE DESCRIBED RESIDENTIAL PROPERTY, ABANDON HOUS ESEWER
SIGNATURE BACKFILL SEPTIC TANKS El
OF PERMI`TTEE_.�_Z�l' LL]
SEEP.P17(S) ❑
CESSPOOLS A6
—VALMATION JACK W. ALLEN
SUPERVISING MECHANICAL ENGINEER
(C K, M.O. CASH