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DIVISION OF RUII INGG AND APPLICATION N SEWER-SEWAGE DISPOSAL
Dnpmtment of Counts Engineer
i County of Lo/ Angel" BUILDING
JOHN A LAMBIE COUNTY ENGINEER ADORES!
lD CASSATT D GRIFFIN SUP T oP SU1LDIND LOCALITY
FOR APPLICANT TO IN 1dr RCRoISIVIT
LEGALa OWNER
Dig PTION LOT NO
MAIL
BLOCK TRACT rJg
ADDRES!
NO OF BLOTS
SIZE OF LOT NOW ON LOT CITY TEL MO
USE DDISTRICT N GROUP YAP
CONTRICT! /.- •1� MBS PG
CONTRALTO � O^i
ADDRESS CONNECTION DATA
STATION DEPTH
Cln L NO
MANHOLE RRFERENCE
STATE
R EGI9TgATIO" NO COUNTY !1 err 0 Lowev
No DESCRI ION OF O �!
FEE
HOUSE SEWER CONNECTING TOTYPE OF CONNECTION LENGTH FROM
PUBLIC SEWER @ S 3 50 Sro Y CURB P L Y L TOP L
SEPTICTANK SEEPAGE PIT OR
PITS AND/OR GRAINFIELD ® S 3 00
OVERFLOW SEEPAGE PIT DRAI"FIELD CO IVP NO SOB COO
EKTN CESSPOOL DRYWELL MANHOLE 0 S 2 00
HOUSE SEWER CONNECTING TO I
PRIVATE DISPOSAL SYSTEM ® S 100 TRUNK PERMIT NO ROAD PERMIT NO L
CONNECT ADDITIONAL BLDG OR STATE ENCROACHMENT
WORK TO HOUBE SEWER $1 00 PERMIT NO
ALTER REPAIR OR ABANDON HOUSE INDUSTRIAL _
!EWER OR DISPOSAL SYSTEM S 100 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
Ovam's PERMT S 1 00
AUTHORIZATION I TOTAL FEE REIMBURSEMENT FEE
i HAVE AT THIS DATE A CONTRACT WITH THE HEREIN N YED CON APPROVALS DATE INSPECTOR SSIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER NEW HOUSE SEWER 19 -D
SIGNED THISrD/A'Y OF���}}} 19— CONNECT ADDITIONAL
OWNER ORie%%:a!C; BUILDING OR WORK
OWNERS AGE SEPTIC TANK,SEEP,PITS)
ADDRESS AND/OR GRAINFIELD
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION CESSPOOLO DRYWELLD
AND STATE THAT THE ABOVE 19 CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE' LAWS REGULATING ALTER REPAIR SEWEROR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REOUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT i AY THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIA PROPERTY BACKFILL SEPTIC TANKS 0
SIGNATURE SEEP PITS) 0 CESSPOOLS 0
OF PERYI EE 4 A '
JOHN A LAM841E CoLatrY ENGINEER VALIDATION ROBERT A WOOD CHIEF PLeG INSPECTOR
CK Y D CASH
'ACO 9111b;