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APPLICATION FOR PERMIT 1
DIVISION OF BUHIDING AND SAFM SEWER-SEWAGE DISPOSAL
Depowtu ant of County Engines
County of Los Angeles FA ¢�
JOHN A LAMBIE Cou NTY ENGINEER
m CASSATTD GRIFFIN SUPTOPBIIILDINa
FOR APPLICANT TO FILL IN LEGALDESCRIPTION LOT NO O
BLOCK "ACT O ADDRESS
NO OF BLT CITY TEL NO
SIZE OF LOT NOW ON LOT
USE OF
BUILDINGS DISTRICT NO GROUP YAP
BK Pa
CONTRACTOR 10. J
ig-
ADDRESS �� CONNE=ON DATA
I
CITYEL NO y� STATION DEPTH
MANHOLE REFERENCE
STATE O� LOWER
REGISTRATION NO / ❑ COUNTY
NO DESCRIPTION OF WORK FEE TYPED TION LENGTH ;ROY
HOUSE SEWER CONNECTING TO Y CURB P L Y L TO p L
PUBLICSEWER @S 3 SO 40
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD ® $3 00
OVERFLOW SEEPAGE PIT DRAINFIELD P C NO
EKTN ,CESSPOOL,DRYWELL,MANHOLE @ $2 00 CO IMP NO POB NO
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM ® $1 00 TRUNK PERMIT NO ROAD PERMIT N
CON N ECT ADDITIONAL BLDG OR STATE ENCROACHMENT
WORK TO HOUSE SEWER ® $I 00 PERMIT NO
ALTER REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM 1 00 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNERS PEfifAT S 00 REINGURSEMENT FEE 2
AUTHORIZATION TOTAL FEE G
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- APPROVALS DATE INSPECTOR SSIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWERLw NEW HOUSE SEWER
SIGNED THI DAY OF I9 CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK
OWNERS AGENT SEPTIC TANK SEEP PITS)
ADDRESS G AMD/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READHIS APPLICATION CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWEROR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT 1 AY PROPERLY REGISTERED AND/OR AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT ABANDON HO PLUG PLUGD
CALIFORNIA OR THAT 1-AU THE LEGAL OWME OF THE ABOVE
DESCRIBED RESIDENTI PERTY BACKFILL SEPTIC TANKS[ISIGNATURE SEEP PITISI ❑ CESSPOOLS
OF PERMITTEE
JOHN A LAMBIE COUNTY ENGINEERcK VAI.(DAT�IOfu�R ROBERT A WOOD CHIEF PLBG INSPECTOR
► N3 sR OCT 2 9 10 A 5.0 0 X
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