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6A6420 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
A0DRr SS
JOHN A. LAMBIE, County Engineer
WILLIAM A. JENSEN, Sup't of Building
LOCALITY
ROSS
FOR APPLICANT TO FILL IN
-7.��LEGAc
R"'Tt
MAIL
TRACT ADDRESS
B',,0C K _2
NO.
rNBI-a(`F.
E'
SIZOF LOT NOW 0 LOT TE L. NO.
USE OF
DISTRICT NO. GROUP IBK MAP PG ROCE'SSEO BY
BUILDINCS
.,
CONTRA,TOR
ADDRESS CONNECTION DATA
STATION DEPTH
❑-TY ELNO
T
STATE MANHOLE REFERENCE
REGISTRATION NO El COUNTY LOWER
NO, DESCRIP'nON OF WORK -FEE---- Trp-E-6-1-C-6-N-N-ECTION LEIN-GTH FROM
HOUSE SEWER CONNE,
.TI TI NG TO CURB P.L. M.L.TO P.L.
PUBLICP,C.NO. 0
SEPYICTANK,SEEPAGE PIT OR CO.IMP.
JOB NO.
PITS AND,OR DRAiNFIELD $10.00 ----- NO.
- EWf -
' CONNECT-ING-T-0- TRUNK PERMIT NO. ROAD PERMIT NO.
SES �R
PRIVATE DIF POSAL SYSTEM S3.00 0
AFFIDAVIT WAIVE EASEMENT
CONNECT ADDMONAL
AFFD
RF'�ORD. INSTR-NO. DA,E
WORK TO HOUSE SEWER @ $3:00
OVERFLOW SEEPAGE PIT.DRAIN,AELD
FXTPi.,c:ESSPOOL,E)RYWELL.?A.ANHOLL @ $5,00 i —L---- '.WY� OR ST.WIDENING
-------4-SFWE�OR DISPOSAL�O'STEM
ENCROACHMENT
PERMIT NO.
------ iNL
DUSTRIAL
WASTE APPROVAL
AL
- CHARGES
OWNETUS -PERMIT $1 2� 00
-- - T-- - - --- ------—---- -
AUTHORIZATION TOTAL-F—EE-----ti CONNECTION CHARGE FEE
REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR To CONNECT THE ABOVE'. DESCR15ED EXISTING DWELLING
TO THE
E P UBLAC SEWER.. APPROVALS DATE i INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF---19—
OWNER OR NEW HOUSE SEWER
OWNER-5 CONNECT ADDITIONAL
M- LD'NG OR WORK
A 0 D RES
E�
I,P IT PTIC TAN." Zr� (S)
I HFE?raV ACKNOWLEDOr THAT I HAVE READ THIS APPLICAYION
AND , AND'/ DRA!NFIELL)
.ATE THAT TH)t ABOVE JS CORRECT AND AGREE TO COMPLY
WITH�5,ALL CO; NT NANCES AND STATE LAWS REGULATfNG
j Y ORD)
r L L'SI 9 INr, AND SEWERS. CESSPOOL Fj DRYWELL F-1
CERTIFY THAT I AM PROPERLY REG R 0
I HEREBY is-YrREE) AND/OR ALTER,REPAIR,SFW� R
LICENSED AS RFQUtRFO BY LOS ANOLFS COUNTY AND STATE OF SEWAGE DISPOSAL.SYSTEM
I
CALIFORNIA OR 'THA, I M THE LEGAL. OWNF46 OF, AND INTEND TO TO _61SCONNFCT PLUG AND
RESIDE IN, THE ABOVE
DESCRIBED RFSIDE7IAL PROPERTY. ABANDON HOURS E SEWER
SIGNATURE 5ACKF1LL5EPTICTANKS ❑
OF PER.MITTFE,-L
SEEP,FIT(5) CJCESSPOOLS
VALIDATION- ROBERT A. WOOD
I SUPERViSING MECHANICAL ENGINEER
CK. M.O. "CASH