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6A 642D APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
sS
JOHN A. LAMBIE, COUNTY ENGINEER
COLEMAN W. JENKINS, SUPT. OF BUILDING
LOCALITY o ze Ci
FOR APPLICANT TO FILL IN NEAREST
CROSS 57: (,....,4{„� lY,..�._.i6��.•
LEGAL '11'
.DESCRIPTION LOT NO. I �- OWNER
s MAIL
BLOCK TRACT "4 ADDRESS jai
NO. OF BLDGS, �� +"' =°� ..
SIZE OF LOT NOW ON LOT CITY " -- TEL, NO.
USE OF DISTRICT NO. GROUP MAP PROCESSED BY
BUILDINGSDISTRICT
PG _
CONTRACTOR
ADDRESS �rOi'- ir'� ' 3;K` t�. w /� CONNEC77ON.DATA
CITY._ .A- %L+-'P✓�"t TEL. NO.. f�� 'f# STATION `.,' DEPTH
J
STATE- - ,A, {{-•"" LIC 2 MANHOLE REFERENCE ✓ 4PPEF#:.,.
LiCEA`d5E NO.._- ._�+'�" f _ tLA'.SS_ •-" /r `
NO. DESCRIPTION OF WORK .--FEE TYPE OF CONNECTION r LENGTH FRO
HOUSE SEWER CONNECTING TO — -- _ Y, CURS 7p L M.L.TO P.L. '5
x PUBLIC SEWER $ "00
SEP76C 3':ANK.SEEPAGE PIT OR —�_ R.C.NO.
PITSAND/OR DRAINFIELD .$10.00 -
CO. IMP. NO. JOB.NO.
�
TRUNK PERMIT NO. ROAD PERMIT NO,
'
PRIVATE DI.CPOSAL SYSTEM @. $3.00
O �-' �
ICN NECT ADOITIDNAL BLDG.OR [ +FPIDAVIT wAiYFR EA5EM[NT RECORD.iNSTR.Nb. DATE
j WORK O HOUSE SEWER � $3.D0 �
,DJ RFLDW SEEPAGE PIT DRAINFIELD
I
I EXTN CES POOL DRYWELL MA1.HOLE 0 Y5.00 CD
_--y HWY.OR 5'F.WIDENING
A TER,REPAIR OR.ABA NDDN HOUSE I
___--_ ..—. _:� _—� �.
SEWER OR DISPOSAL S
ISPOSAXSTEM $3.00LI J
( _ STATE ENC ROACPIMENT (�
PER MIT NO, 6/)
INDUSTRIAL
WASTE.APPROVAL
CHARGES
y 'p� yy�} /� FEE
TQTAL CLE CONNECTION CHARGE FEE
1 HAVE AY THIS DATE A CONTRACT WITH THE HEREIN .NAMED CON- REIMBURSEMENT rF_E.
TRACTOR.TO„CONNECT THE, ABOVE DESCRIBED EXISTING DWELLING --”- ------ —y---- - ----------
TO THE PUBLIC SEWER.. APPROVALS D TE I INSP TOR'S SIGNATURE
SIGNED THIS DAY OF —
OWNER OR NEW HOUSE SEWER .;�1
_
OWNERS AGENT__ - CONNECT ADDITIONAL -
ADDRESS BUILDING OR WORK -
T— SEPTIC TANK,SEEP,PIT(S).
1 HEREBY ACKNOWLEDGE THAT i HAVE READ THIS APPLICATION AND/OR DRAINFIELD
ANLL STATE THAT THE .ABOVE IS CORRECT AND AGREE TO COMPLY —
WIT'H ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CE55FOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT I ANP PROPERLY REGISTERED AND/OR ALTER,REPAIR.SEWER OR
CEI -
LINSEO AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CAL F'0 RNIA OR THA i AM THE. LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE 'IN, SHE A DES BED RESIDENTIAL PROPERTY. ABANDON HOUSE SEWER
SIGNATURE „ ❑ — -a
OF PER.MTTTE BACKFILL SEPTIC TANKS '
----- SEEP.PIT f5) ❑ CESSPOOLS n'
VALIDATION JACK R. ALLEN
CK. M.O. CASH SUPERVISING MECHANICAL ENGINEER
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