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78Ao42n 80 APPLICATION FOR PER:IVIf. -�.. .
COUNTY OF LOS ANGELES SEWER-SE A"GE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION ADD�RESs � � r �� -
JOHN A. LAMBIE, County Engg'IM 0 i— w
WILLIAM A. JENSEN, Supt of$molding LOCALITY ._
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
DESCRIPTION LOT NOfS 6 34 EAIL V119 1 - OWNER
BLOCK TRACT e ., MAIL
ADDRESS
NO.OF BLDGS
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USOF
BUILDINGS DISTRICT NO. GROUP MAP PROCES�2D BY
BK PG ( �.
CONTRACTOR � ._-3t,•b,,.�.,.�^-- L ; �k. - � .'�° { '
ADDRESS `/ CONNECTION DATA
CITY , --� TEL.N0. L STATION Zl.® ` DEPTH
STATE MANHOLEEF'ERENCE d
REGISTRATION NO. y e, / COUNTY r ,r e LOWER,
N0. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER fLA $3.0014- TYPE OF CONNECTION LENGTH FROMJ'
SEPTIC TANK,SEEPAGE PIT OR Y. F
PITS AND,/OR DRAINFIELD @ S3,00CURB P.L. M.L.TO P.L.
OVERFLOW SEEPAGE PIT,DRAINFIELD -
EXTN.. CESSPOOL DRYWELL @ $7..00
HOUSE SEWER CONNECTING TOP.C.NO.
PRIVATE.DISPOSAL SYSTEM @ $1.00 CO.IMP.N0. JOB NO. y.
CONNECT ADDITIONAL.BLDG.OR Pr
WORK TO HOUSE SEWER. @ $1,00 TRUNK PERMIT N0. ROAD PERMIT NO:� r, V
AuTER,REPAIR OR ABANDON HOUSE STATE ENCROACHMENT tr,'
SEWER OR DISPOSAL SYSTEM @ $1.00 HERMIT 140. t O�.
INDUSTRIAL U
WASTE APPROVAL _ 94
CHARGES
OWNER'S PERMIT 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE ` t REIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS R DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS DAY O 19_ NEW HOUSE SEWER
OWNER ORj, � r�' � CONNECT ADDITIONAL
OWNERS AGENT � /��,�'�'' `� BUILDING OR WORK
ADDRESS SEPTIC TANK.SEEP.PIT(S)
AND/OR DRAINFIELD
1 IIERCPY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION -AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL ❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL.SYSTEM
1 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 AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RES 4DEN A ROPERTY, BACKFILL SEPTIC TANKS Cl
SIGNATURE ,ys SEEP. PIT(S)) ❑ CESSPOOLS []
OF PERMITTE
VALIDATION ROBERT A. 'WOOD
CK. M.0. CASH SUPERVISING MECHANICAL ENGINEER
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