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CE8D88.60 APPLICATION FOR PERMIT 7
78A642D COUNTY OF LOS ANGELES SEWER-SEWAGE .DISPOSAL 1
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION nDORESSG
JOHN A. LAMBIE. County Engineer
WILLIAM A. JENSEN, Supt of Building LOCALITY <
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.Vcap
LEGAL , OWNER -
DESCRIPTION LOT NO. -
BLOCK TRACT 7� �/�� MAIL
7 ADDRESS -�
N0.OF BLDGS.
SIZE OF LOT NOW ON LOT '� CITY EL.'N0.
USE OF DISTRICT NO. GROUP MAP PROCESSED BY
BUILDINGS BK PG'
CONTRACTOR --
ADDRESS /� CONNECTION DATA V - -
CITY EL.N0. / STATION DEPTH -
/ STATE MANHOLE REFERENCE UPPER ,
REGISTRATION N0. d Q COUNTY
NO. DESCRIPTION OF WORK FEE _.
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3.00 TYPE OFC CTION LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR Y. RB' P.L. M.L.TO P.L:
PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE'PIT',DRAINFIELD
EXTN..CESSPOOL. DRYWELL @ $2.00
HOUSE SEWER CONNECTING TO P.C.NO.
PRIVATE DISPOSAL SYSTEM @ $1.00 -CO.IMP. NO. JOB NO.
CONNECT ADDITIONAL BLDG.OR
WORTO HOUSE SEWER @ $1.00 TRUNK PERMIT N0. ROAD PERMIT N0, O
K
ALTER,REPAIR OR ABANDON HOUSE STATE ENCROACHMENT V
SEWER OR DISPOSAL SYSTEM @ $1.00PERMIT NO. 0
INDUSTRIAL - V
WASTE APPROVAL pl
CHARGES Ua1
OWNERS PERMIT $ 200 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE Q REIMBURSEMENT FEE
CON-
TRACTOR TO CIONNECT THE ABOVE DESCRIBED EXIIST NGDATE A CONTRACT WITH THE HEREINAMED DWELLIING APPROVALS DATEINSPECTOR'S SIGNATUR
TO THE PUBLIC SEZAR.0j /
SIGNED THISDAY OF 19 NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AG BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD
1 HERE Y ACKNOWLEDGE THAT 1 AVE 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 COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT M THE L OF THE ABOVE
DESCRIBED RES
IDEN L Pill PERTY. BACKFILL SEPTIC TANKS ❑ _9��/
SIGNATURE SEEP. PIT(S) [ICESSPOOLLS.
OF PERMITTEE 7sr /,i
®P ,,�, LIDATION f ROBERT A. WOOD
cK M.Q. CASH SUPERVISING MECHANICAL ENGINEER
LAL02 2 4 5% 'JUL271 0 A 7.00-