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6A64ZD APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A, LAMBIE, County Enggineer ADDRESS 's�
WILLIAM A IENSEN, Sup'i of Building
LOCALITY
FOR APPLICANT TO FILL 1N CROSS ST.
LEGAL , '# ,
DESCRIPTION LOT NO r ( f OWNER
BLOCK TRACT NAIL
ADDRESS ` �3
SIZE OF LOT K0.OF BLDG§.
HOW ON LOT
USE OF CITY TEL NO
BUILDINGS DISTRICT NO. GROUP NAP PROCESSED BY
CONTRACTOR t '. °° i '/ .t BK.. pG� i
ADDRESS ,4Y '� Z✓ LC. $p-=•.
�,t
CONNECTION DATA
'T NO.
CITY y d '' { ✓ STATION DEPTH : ...-1
TEL. `
REGISTRATION t STATE MANHOLE REFERENCE - UPPER
COUNTY
No. DESCRIP ION F FEE
PUBLICS SEWER CO)
i0 00 ►�p
SEPTIC TANK,SEEPAGE PIT OR TYPE OF CONNECTION LENGTH FROM e
PITS AND/OR DRAINFIELD @ ,00 Y. ' CURB P.L. M.L.TO P.L. r,
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN..CESSPOOL.DRYWELL @ $ .00 }
HOUSE SEWER CONNECTING TO I'
PRIVATE DISPOSAL SYSTEM @ $.00 CO.IMP• N0. ."� P.C.H0. C7
JOB N0, u
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT N0. ROAD PERMIT N0,
WORK TO HOUSE SEWER 5.00
i ACTERrRGR#}A-SR ABANDON HOUSE
SEWER t. STATE ENCROACHMENT
_ @ 51.00 PERMIT NO,
INDUSTRIAL IL
WASTE APPROVAL IL
L0
�iyw�+ CHARGES Z
O•rNER'S PERMIT 3 Z 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE a ,1 REIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF- 19 NEW HOUSE SEWER
OWNER OR
OWNERS AGENT CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PIT($)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ElDRYWELL
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. ALTER,REPAIR,SEWER OR
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR SEWAGE DISPOSAL SYSTEM
LICENSED AS REQUIRED BY LOS ANGELES CO T -AND STATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT I AM TH .LEGA -•0 E ;,OF THE AB9.VE ABANDON HOUSE SEWER
DESCRIBED RESIDENTIAL F,RgPEI �' y° BACKFILL SEPTIC TANKS ❑
SIGNATURE p %',. ,, > 9` SEEP.PIT(S ❑ CESSPOOLS
OF PERMITTEE �
. ATION ROBERT A. WOOD
cIC- N,D, CASH SUPERVISING MECHANICAL ENGINEER
Y.,.
sAaaz4 D- APPLICATIO FOR PER LT
COUNTY OF LOS ANGELES SEWER--SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A, LAMBIE, CoustY Engineer ADDRESS i•' t a, ?
WILLIAM A. JENSEN, Supt of Building LOCALITY ti '
NEAREST
FOR APPLICANT TO fII.L IN CROSS ST.LEGAL
DESCRIPTION LOT NO. .. OWNER ' -a '
i
BLOCK TRACT MAIL
ADDRESS
,NO.OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF DISTRICT NO. GROUP MAP PROCESSED BY
BUILDINGS 1
BK PG
CONTRACTOR
ADDRESS '' y I _.116, r` CONNECTION DATA p
CITY TEL..NO. ." i f~moi STATION e t DEPTH
REGISTRATION NO. j ,��? �` _ —STATE MANHOLE REFERENCE i-�f r `'; UPPER
LJ COUNTY LOWER
No. I DESCRIPTION OF WORK FEE a
/ HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ S ,00 ' TYPE OF CONNECTION LENGTH FROM <
SEPTIC P
ITS ANDANK, AEPAGtE PIT OR S .00 Y' ", CURB P.L. M.L.TO P.L. i
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN.,CESSPOOL.DRYWELL @ $
.00
HOUSE SEWER CONNECTING T6 P.C.NO.
PRIVATE DISPOSAL SYSTEM @ S-00 CO..IMP. NO. JOB NO. V
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT NO
WORK TO HOUSE SEWER @ S.00 -�
SEWER OR DLI,P ALBYS7DEN HOUSE C? AO STATE ENCROACHMENT U
PERMIT NO.
INDUSTRIAL n.
WASTE APPROVAL N
CHARGES z
OWNER'S PERM $ 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE S +l REIMBURSEMENT FEE
CON-
TRACTOR TO CIONNECT THE ABOVE DESCRIBED EXIISTINGDATE A CONTRACT WITH THE HEREINAMED DWELLIING APPROVALS DAVE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS__--.—DAY OF 19` NEW HOUSE SEWER
OWNER OR %,. r::. CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADDRESS [ABANDON
PTIC TANK,SEEP.PIT(S)
D/OR DRAINFIELO
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS. CORRECT AND AGREE TO COMPLYSSPOOL ❑ DRYWELL.
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATINGTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. WAGE DISPOSALS'YSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/ORSCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF HOUSE SEWER
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF;:THE ABOVEDESCRIBED RESIDENW)T L PP�i FRTYy' j CKFILL SEPTICTANKS ❑SIGNATURE EP.PIT ES ❑ CESSPOOLS
�
OF PERMITTE �--'I � -'"l'I'� "41
ALII7ATION ROBERT A. WOOD
ry
U.o. CASH SUPERVISING MECHANICAL ENGINEER
44
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