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76A6320 APPLICATION FOR 1 PE ■MIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING y
BUILDING AND SAFETY DIVISION
ADDRESS
JOHN A. LAMBIE; County En (neer
WILLIAM A. JENSEN. Sugi t of wilding LOCALITYNEAREST
FOR APPLICANT TO ]FILL IN
CROSS ST.
DESLEGAL A
CRIFTION LOT N0. �' .!�-° OWNER
BLOCK TRACT rMAIL
ADDRESS'.
NO.OF BLDGS. r
SIZE OF LOT NOW ON LOT - CITY s' -�', � TEC NO
BUILDINGS
DI DISTRICT NO. GROUP MAP PROCESSED BY
BUILDINGS ==' e -- BK PG e'
CONTRACTOR ry = f
ADDRESS _:� .,;ti A.? �„
� CONNECTION DATA
CITY TEL STATION 7 DEPTH
a
ySTATE
MANHOLE£REFERENCE 7 UPPER
REGISTRATION-mo,/f �. � 'r
COUNTY
NO. DESRIPTION OF WORK E
HOUSE SEWER CONNECTING TO
PUBLIC SEWER CC-) $3.00
TYPE OE-Z6NNECTION LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR Y. -`` 'CURB ; P.L. M.L.TO P.L.
PITS AND/OR DRAINFIELD @ $3..00 - -
OVF_RFLOV1 SE"'PAGE PIT,DRAINFIELD 2
€Y,TFa.,CrS�1; OL.DRYWELL @ _$2:00
HOUSE SEWER CONNECTING TO r;�� P C.N0,
PRIVATE DISPOSAL SYSTEM $1.00 CO.IMP. NO. JOB N0.
CONVECT ADDITIONAL BLDG.OR ,.�.,,, y;,/
WORK TO HOUSE SEWER :G,.•t,r.--x's ,f�_ $I.00 .� , TRUNK PERMIT N0: ROAD PER N0. �, OO
ALTER.REPAIR OR ABANDO HOUSE STATE ENCROACHMENT
_ SEWER OR DISPOFERMIT N0, Q
INDUSTRIAL U
WASTE APPROVAL W
CHARGES
OWNER'S _PERMIT s_ 2 Op CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE OW I 1.1 ` REIMBURSEMENT FEE
I HAVE: AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON.
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLINGAPPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SERF ..
SIGNED THIS =QDAY OF
NEW HOUSE SEWER
OWNER ORCONNECT ADDITIONAL
_.i
OWNERS AGENT �+' -�✓ - " .s✓__ -'" r`�
-+w - BUILDING OR WORK _
ADDRESS � � � SEPTIC TANK,SEEP,PITS)
ANDfOR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL [I
WITH Ai.L, 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 DISCOHOUSE NNECT
D J - -
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF'.THE ABOVE
DESCRIBED RESIDENT! ,:PROPERTY _ Jr BACKFILL SEPTIC TANKS 0 t
SIGNATURE ted' - �' t- SEEP.PIT IS)
. ❑ CESS �POOLS l
OF PERMITTE :`f
e VALIDATION,,— ROBERT A. WOOD
CM. AL.0. CASH ' SUPERVISING MECHANICAL. ENGINEER
.''