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T6A APPLICATION FOR PERMIT
62.4
COUNTY OF LOS ANGELES SEWER--SE`, ,AGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION TNE
NG py
JOHN A. LAM]�IE, COUNTY ENGINEER ADDRESS '? ,° rd ^
COLEMAN W. JENKINS, SUPT OF BUILDING
ITY
STFOR APPLICANT TO FILL 1N '" u
s L
?PRINT O TYPE ONLY t._.- - - - ----
DESCRIG TION _LOT NO d'`6. OWNER
MAIL
BLOCK____ TRACT k 3 r �.-�a --�--� -- ADDRESS
NO. OF BLDGS.
SI-ZE OF LOT NOW ON LOT CITY TEL.. NO
_ -__
USE OF .y DISTR.ICI NO. GROUP CLASS MAP p,'; ESSED BY
BUILDINGS BYE PS
sON1RACTOR - Y .— L/�` ,. _ '`- _ j,l'; ;
- ~
ADDRESS t "yam r _ CONNECTION DATA
CITY �� TEL. n-
TEL. DEPTH
�' MANHOLE REFERENCE
STA' .yw Fv LLC ,yen, ,d Y _
ICEN _ --__-r'LASS
LSE NO;
. rs '.''� LOWER
NO. mO
DE F WORK 1-EE -
_-._ TYPE OF'CONNECTtON LENGTH FROM
y' r
HOUSE.SEWER CONNECTING TO y �` Y. CURB M.L.TO P.L. .-
P EWER - -
_.._ _ .
SEPTIC TANK SEEPAGE PIT O.R "�' P.C. NO JOBNO.
—� PITS AND OR.DRAINFIELD @ $I.D.00 CO.!MP NO. J
HOUSE S WLR .ONNECTING TO _- I
jPRIVATTRUNK PERMIT NO. ROAD PERMIT NO. -
E'.DISPOSAL SYSTEM � $3.00
ONNECT ADDITIONAL BLDG 7R y AFF IDAVI WAMN [ASE:ME kHm RECORD. iNSTR NO. DATE }
WORK TO HOU E SEWER Q $3.00
OVERFLOW SEEPAGE PIT.DRAINFIELD
EXTN,C€SSPOOL..DRYWELL,MANHOLE @ $5.00 -HWY. QRST.WIDENING
. - - -
ALTER.REPAIR OR ABANDON HOUSE —j
.',EWER ORD 5P0':iAL SYSTEM $3.00 --
__. S . I--..._.-- STAT'c FNCROA CHMENT
Lu
4 1 PERMIT NO. Lu
INDUSTRIAL
`
WASTE APPROVAL
CHARGES
OWNERS PERMIT s ; oo ---- ----------—
AUTHORIZATION TOTAL FEE ' e4-
CONNECTION CHARGE FES --
I HAVE AT THIS DATE A.CONTRACT WITH THE HEREIN NAMED CON- REIMBUFME�pMENT`_FEE
T�r
w7.
TRA CTOR TO CO N.
TO THE UBLIC SEWER.NECT THE ABOVE DESCRIBED EXISTING:.DWELLI.N.G AI�FRC3 JAda " � DATE IpVSPECTO R'S SIGNATURE
P
SIGNED THIS DAY OF_,_ --
OWNER OR � - NEW HOUSE SEWER _
OW
N E R S AGENT ,
_
,i - - - -- - ---'"
„t- CONNECT ADDITIONAL
✓ BUILDING OR WORK {(4{
ADDRESS _ ._. __. _ —__— ._.__ _____ 1 --_
"— - ga~PTIC.TANK,SEEP,PIT(S) I
i HEREBY At KNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRA;NFIELD
AND STATE THE, THE ABOVk:..IS CORRECT AND AGREE TO COMPLY
WIT HALL COUNTY ORWNANCE5 AND STATE LAWS REGULATING
PLIJ Me ING AND SEV✓£R,. CESSPOOL D DRYWELL
HEREBY CERTIFY THAT I AM PROPERLY REGIS.,FRED AND/OR ALTER.REPAIR.SEWER OR. ------
CEN',€D AS REQUIRED Y LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM i1
AL'FORN A OR THAT I :Ki THE LEGAL 0'WN OF AND INTEND TO DISCONNECT PLUC AND -`
AES:,E N_ THE ABOy. OESCRi6ED REST 7CAL ROI` PITY. ABANDON HOUSE SEWER )I
•
SIGNATURE
OF FER.MTTT€L ' ; >;' BACKFf LI
_k _
` CESSPOOLS � � •;'1
VALIDATION JACK R. ALLENv
c�.! J M.D BASH SUPERVISING MECHANICAL ENGINEER