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E-eG3 11-55 APPLICATION FOR PERMIT
DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Department of County Engineer
County of Los Angeles BUILDING
JOHN A. LAMBIE, CGUNTY ENGINEER ADDRESS
CASSATT 0GRIFFIN, SUPT OF BUILDING LOCALITY
FOR APPLICANT TO FILL IN NEAREST
. = `* �%,
LEGAL OWNER
DESCRIPTION- RIPTIRNLOT-Nm-o
MAIL
BLOCK TRACT 3
ADDRESS
NO.OF BLDGS
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE Of DISTRICT NO, MAP
BUALDIN
-r BK PG
CONTRACTOR
CONNECTION DATA
ADDRESS
CITY T EL� NO STATIONDEPTH
MANHOLE REFERENCE
0 STATE
REGISTRATION NO,
COUNTY
NO. ; DESCRIPTION OF WORK FEE
TYPE OF CONNECTION LENGTH FROM
L HOUSE SEWER CONNECTING TO
�Pl M�L.TO P,L.PUBLIC SEWER @ $3.50
-SE- TA-WIC SEEPAGE- - --
SEPTIC , PIT QR
PITS AND/O DRAINFIELD l $3.00
OVERFLOW SEEPAGE PIT,DRAINF15LD OVERF P. C. NO.
EXIN.,CESSPOOL.DRYWELL,MANHC)LE Qu2.00 VP.
HOUSE SEWER CONNECTING TO
PRIVATE DI$POSAL SYSTEM_ ____ Cq1 $1.0_0_ I TRUNK PERMIT NO. ROAD PERMIT NO.
CONNECT ADDITIONAL BLDG,OR STATE ENCROACHMENT
WORK TO HOUSE SEWER 6X" $1.00 PERMI T N 0.
ALTER.REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM 1.00
WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT s00
--- REIMBURSEMENT FEE
AUTHORIZATION L TOTAL FEE :-Lrj. I
I HAVE HEREIN NAMED CON-
AT THIS DATE A CONTRACT WITH THE APPROVALS D}ATE !NSP.ECTOR';SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER.
NEW HOUSE SEWER
SIGNED THIS---------DAY OF_ 19--_ CONNECT ADDITIONAL
OWNER ORBUILDING OR WORK
OWNERS AGENT SEPTIC TANK,SEEP,PIT(S)
ADDRESS AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION CESSPOOLL) DRYWELLO
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER O
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT 1. AM PROPERLY REGISTERED AND/OR
LICENSED AS REQUIRED M I LOS "GELES C NT 10 STATE PF DISCONNECT PLUG AND
p A
CALIFORNIA A i T E A 4WNEr ABANDON HOUSE SEWER
RNIA OR THAT I A I% L-,p THE AA*VE
DESCRIBED RESIDE T BACKFILL SEPTIC TANK$
SIGNATURE
SEEP.PIT(S) LI CESSPOOL
Sr
OF PERMITT-r-_.--
IOHN A. LAME#IE, COUNTY ENGINEER VALIDATION ROBERT A.WOOD, CHIEF PLEG. INSPECTOR
M.01 CASH
7 2 '2 4
C 4.5 '