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6A&42D42D61 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER--SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A, LAMBI£, County Engineer
ADDRESSs �K _
WILLIAM A. JENSEN, Supt of Building_ LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL }
DESCRIPTION LOT NO i'. =may + OWNER
BLOCK TRACT ° MAIL
_ADDRESS
)NO.OF BLDGS. Iy
SIZE OF LOT NOW ON LOT °' CITY TEL. NO.
USE OF
BUILDINGS DISTRICT NO. GROUP $
BK MAP Pf3 PROCESSED1Y
CONTRACTORS
ADDRESSCONNECTION DATA
CITY ✓ Y TEL.NO STATION
5 DEPTH
--� STATE MANHOLE REFERENCE
REGISTRATION NO. $ COUNTY g LOWER'
W DESCRIPTION OF�1—5(�RK FEE -
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $8.00 TYPE 0 '64"IKTION LENGTH FROM"
SEPTIC TANK,SEEPAGE PIT OR Y. CURB,:' P.L. M.L.TO P.L.
PITS AND/OR DRAINFIELD SB,00
OVERFLOW SEEPAGE PIT,DRAINFIELD r
EXTN..CESSPOOL.DRYWELL. @ 52.00 - '.^ - - - IY
HOUSE SEWER CONNECTING TO P.C.NO. O
PRIVATE DISPOSAL SYSTEM @ $1,00. CO.IMfi.NO.r' JOB NO.
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT N0. - fle
WORK TO HOUSE SEWER @ $1.00
ALTER,REPAIR OR ABANDON HOUSE STATE ENCROACHMENT r/ ' i
SEWER OR DiSPOSAI.SYSTEM
P $1.00
PERMIT N0, r
INDUSTRIAL
WASTE APPROVAL a'
V9
CHARGES Z
OWNER`S PERMIT $ 2 OO CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEF. 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: 19— NEW HOUSE SEWER
OWNER OR �+ t.� CONNECT ADDITIONAL
OWNERS AGENT _i,_ L BUILDING OR WORK
ADDRESS SEPTIC TANK.SEEP.PIT($)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE. ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL DRYWELL
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING ERS. SEWAGE DISPOSAL SYSTE
I HER CERT.Y THAT 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICEAS R IRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIF IA THAT I AM THEL OW5ER Of THE ABOVE
DESC IS '' I PROPERTY ,f BACKFILL SEPTIC TANKS
SIGNATURE C
y,e- SEEP.PIT(S ❑ CESSPOO.L$
,�'.
OF PERMITTE
VALIDATION ROB5RT A. WOOD
CK. Y.0. CASA; .SUPERVISING MECHANICAL.ENGINEER
4: �, 3 7.000