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6A 642D-CE808 —10-71 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS
LOCALITY
FOR APPLICANT TO FILL IN
NEA REST
-T. C
LEGAL _._--—.—_
DESCRIPTION LOT NO.
OWNER
BLOCK TRACT 1 d.j MAIL
�J
ADDRESS
y3 '--NO. OF BLDGS.
SIZE OF LOT C:% NOW ON LOT CITY TEL. NO.
USE
BUILDINGS °'""�+F' t DISTRICT NO. GROIJP MAP PROCrSSEO 61'
SK PG
(CONTRACTOR , ( "L
�AODRESS , . -� C" s CONNECTION DATAW
STATIONr� e'�1.t:=i DEPTHY _'',<• TEL. NO, . < -.}.�... . `r !TE _ LIC
LICENSE NO: ^ MANHOLE REFERENCE
r C,LA55 l
No. DESCRI TIO OF WOR FEE --- -- a__._ ____ LOWER
_ TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L.
PUBLIC SEWER @ $7,00
SEPTIC TANK.SEEPAGE PIT OR P.C.NO.
PITS AND/OR DRAINFIELD @ $10.00 CO. IMP.NO. JOB NO.
HOUSE SEWER CONNECTING TO W }
TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM E3.00 0
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAI4ER -EASEMENT RECORD.INSTR.NO. DATE V
WORK TO HOUSE SEWER @ $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD OC
EXTN..CESSPOOL,DRYWELL. 0 $.3.00 O
ALTER,REPAIR OR ABANDON HOUSE HWY•OR ST,WIDENING
-_ SE_W_ER OR DISPOSAL SYSTEM 0 $3.00 _ STATE ENCROACHMENT yuj
MANHOLE $7.00 PERMIT NO.
-US d.
_—_ —
-- -- INDUSTRIAL H
WASTE APPROVAL
OWNER'S PERMIT $ 3 00 CHARGES
AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTORTO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING —
TO THE PUBLIC SEWER, APPROVALS DATE IN S.C4R..$` GNA'URE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER l
OWNERS AGENT CONNECT ADDITIONAL.
I ADDRESS BUILDING OR WORK
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION SEPTIC TANK,SEEP,PITS)
AND/OR DRAINFIELD
.AND STATE THAT THE ABOVEIS CORRECT AND AGREE TO COMPLY ----------
WITH ALL COUNTY ORDINANCES AND ST,-TE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL 4+
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR.SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I THE LEGAL WNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE AS DESCRIBED RE D�T ��fRO`PE RTy. ABANDON HOUSE SEWER
SIGNATURE
OF PERMYfTEE_ _ BACKFILL SEPTIC TANKS
- SEEP.RIT(S) ❑ CESSPO❑OLS
VALIDATICIcK. M.0. CASH
'6 A`642D`•CE808 -10-71 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION FNA
G )
S ,; � •/�V - YY
Y
T r
FOR APPLICANT TO FILL IN ST.
LEGAL
DESCRIPTION LOT NO. OWNER
G MAIL
BLOCK P, TRACT r � ADDRESS
NO. OF BL G5.
SIZE OF LOT G� � NOW ON LODT CITY TEL, NO.
USE OF
BUILDINGS DISTRICT NO. GROUP I MAP P.5 PRO ESSED BY
OK
CONTRACTOR '�N 3 SL. / 62 t"- -I
ADDRESS f , �. CONNECTION DATA
�. STATION DEPTH
CITY �7 TEL. NO.S TATE
Lc
LICENSE NO. / r CLASS MANHOLE REFERENCE UPPER
LOWER
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L.
PUBLIC SEWER 0 $7.00 R'C.NO.
SEPTIC TANK.SEEPAGE PIT OR JOB NO.
PITS AND/OR DRAINFIELD 0 $10.00 CO. IMP,NO.
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM @ S3.00 B 0
TRUNK PERMIT NO. �. /ROAD PERMIT NO. d
0-
CONNECT ADDITIONAL
BLDG.OR AFFIDAVIT WAIVEI E I ,RECORD.INSTR.NO. DATE
WORK TO HOUSE SEWER 0 $3.00 f
OVERFLOW SEEPAGE PIT.DRAINFIELD i Ix
EXTN..CESSPOOL.DRYWELL. $5.00 0
ALTER.REPAIR OR ABANDON HOUSE HWY.OR ST.WIDE NG F
SEWER OR DISPOSAL SYSTEM 53.00 _ STATE ENCROA _ MENT W
MANHOLE
$7.00 PERMIT NO.
-- INDUSTRIAL N
WASTE APPROVAL Z
CHARGES
OWNERS PERMIT S 3 00
AUTHORIZATION I TOTAL FEE ', CONNECTION CHARGE FEE
1HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS
TO THE PUBLIC SEWER. DATE INS N T RE
SIGNED THIS DAY OF 19_
J
OWNER OR NEW HOUSE SEWER
OWNERS AGENT
CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
I HEREBY ACKNOWLEDGE THAT i HAVE READ THIS APPLICATION SEPTIC TANK.SEEP,PITS)
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY AND/OR DRAINFIELD
WIT HALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL Cl DRYWELL
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER.REPAIR.SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OW OF. AND INTEND TO DISCONNECT PLUG AND
RESIDE IN. THE ASO '`DESCRIBED RE51 NTIA�I PROPITTY. ABANDON HOUSE SEWER
SIGNATURE ♦ BACKFILL SEPTIC TANKS ❑
OF PERMffTEE_ '.' __
SEEP.PIT(S) [I CESSPOOLS
❑
VALIDATION CK. M.O. CASH
L c 21-03 aV 23 1 0 Q 6.0 0