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7RA6420 APPLICATI N FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING _
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FOR APPLICANT TO FILL IN cnoae°ST 2DLEGAL
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DESCRIPTION LOT NO 0 OWNER JL/
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ADDRESS CONNECTTON DATA
CITY' TEL No STATION DEPTH
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REGISTRATION NO COUNTY MANHOLE REFERENCE LOWER
NO DESCRIPTION OF WORK FII! TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y CUR[ PL ML TOP L
PUBLIC SEWER d °BOO r
SEPTIC TANK SEEPAGE PIT OR O NO
JO
PITS AND/OR DRAINFIELD C [1000 CO IMP NO OS NO
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HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO ,
PRIVATE DISPOSAL SYSTEM [S 00 OL
CONN ECT ADDITIONAL BLDG OR AFFIDAVIT N[O[[ !O[XtXi RECORD INSTR NO DAT[ O
WORKTO HOUSE SEWER O 33M r
OVERFLOW SEEPAGE PIT DRAINFIELD lVY
BXTN CESSPOOL DRYW[LL MANHOLE 0 S°00
ASANDO HOUSE NWY OR ST WIDENING y
SEWER TEM 0 []00
PENCROACHMENT ` Z
PERMIT
NO 1
INDUSTRIAL
WASTE APPROVAL
OWNER'S PEANUT s z 00 CHARGES
AUTHORIZATION I TOTAL FEE 3702
CONNECTION CHARGE FE[
I HAVE AT THIS DAT! A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT F![
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SSW[R APPROVALS
ROV T DAT[ INSPECTOR S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OW HERS AGENT
CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
1 HERESY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION SEPTIC TANK BEEP PIT(S)
ANO/OR GRAINFIELD
AND STATE THAT THE ABOVE I° CORRECT AND ACRE, TO COMPLY
WIT" ALL COUNTY ORDINANCES AND STAT[ LAWS REGULATING CESSPOOL
PLUMBING AND SEWERS ❑ DRYWELL ❑
I HERESY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM t
CALIFORNIA AT 1 THS LEGAL OWIVR OF D I [ND TO DISCONNECT PLUG AND
RESIDE IN E D[SC IBLD REB10 !
ABANDON HOUSE SEW ER
SIOHATUR
OF P I BACKFILL SEPTIC TANKS ❑ P E
SXeP PIT(S) ❑ CESSPOOLB
/"yALROBERT A WOOD
m 0 C
cK M G CASH SUPERVISING MECHANICAL ENGINEER
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APPLICATION FOR PERMIT 7
DrMON OF BUU.DBNG AND SAFETY SEWER—SEWAGE DISPOSAL - 1
D"mbn
CDmty nt of Come! Engineer
of Los Angelos BUILDING qL
P
WM J PDX, COUNTY ENGINEER ADDRESS
CASEATTD GRIFFIN.SIO•'T OF BUDJBING LOCALITY C 1
FOR APPLICANT TO FILL IN !Na
EARBY
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DESCRIPTION LOT NO OWNER
BLOCK THAT 2 MAIL
SIZE OF LO
c ADDRESS /
v l-f ND OF'LOGS
W ON LOT CITY TEL NO7726 1
USE OF
BUILDI GS �'1T DISTRICT NO GROUP YAP
CONTRALTOL� T SK PG
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ADDRESS CONNECTION DATA
CITY TEL NO STATION 2 DEPTH
STATE MANHOLE REFERENCE / UPPER
REGISTRATION NO COUNTY �q rffM�
No DESCRIPTION OF WORK FEE
ROUSE SEWER CONNECTING TO TYPE ECTION OM
PUBLIC SEWER 3 SO SO Y URB' P L N L
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1 DO
CONNECT ADDITIONAL BLDG OR ^L P C MO
WORK TO HOUSE SEWER I DO CO IMP NO 13 JOB NO
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM 1 00 TRUNK PERMIT NO ROAD PERMIT NO
DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT
ANO/OR DISPOSAL SYSTEM 1 00 PERMIT NO
SEPTIC TANK SEEPAGE PIT OR
PS AND/OR DRAINFIELD 3 00 INDUSTRIAL
CET
SSPOOL-
•DRYWELL WASTE APPROVAL
SPECIAL CONDITIONS ONLY Z 00 CHARGES
� ,r CONNECTIOII CHARGE FEE
OVVNWS S` t 00
AUTHORIZATION ` TOTAL F$E T O REIMBURSEMENT FEE
RTHIS
DATE CONTRACTED WITH
HEREIN
EXT � IAPPROVALS GATE INS CTORfSIGNATURETACTORTOCONNECT THE ABOVE DESCRBEDEXISTING
WELLN6
�
TO THE PUBLIC SEW • r
�SIGNEDfTHIS Ef 3- DAY OF �Ig V 6 NEW xousi SEWER
OWNER ORCONNECTADDITIONAL I'
OWNERS •AGENT O 1 BUILDING OR WORK
SEPTIC TANK SEEP PIT(S)
ADDRES AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE REB THIS APPLICATION CESSPOOL 0 DRYWELL 0
AND "ATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWER 8 ALTER,REPAIR SEWER OR
BKWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT 1 AN PROPERLY REGISTERED AND/OR
LICENSED AS REOUIRED BY LOS ANGELES COU AND STATE OF 0ISCONNiCT PLUG AND
CALIFORNIA OR THATAAIIyyyAM THE LEGAL OW Of THE BOVE ABANDON HOUSE SEWER
DESCRIBED RESIDENT] BACKFILL SEP IC TANKS❑
SEEP PITJS) CESSt00 LS
310MATURB
OF PERYITT -
WILLIAM J FOX. ENGINEER MMATION R.A WOOD.CHIEF PLEG. INSPECTOR
1ACo3 5 8 an FEB29 4 450 ID