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APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING ,
ADDRESS =
JOHN A. LAMBIE, Count Engineer
C1iSSATT D. GRIFFIN, Supt of Suildinq LOCALITY -
NEAREST
FOR APPLICANT TO FILL TM
CROSS ST.
LEGAL
DESCRIPTION LOT NO. f° OWNER
a
BLOCK TRACT MAIL
_ ADDRESS
NO.OF 3LOGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO,
USE OF
BUILDINGS DISTRICT NO. GROUP MAP PROCESSED BY
BK PG
CONTRACTOR - , J
ADDRESS - CONNECTION DATA
CITY TIL.FdO. STATION DEPTH
STATE MANHOLE REFERENCE • OWER
RIST
EGRA'I ON NO, [j COUNTY
NO, DESCRIPTION OF WORK FEE —"
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3.00 '' TYPE OF CONNECTION LENGTH FROM ,g
SEPTIC TANK.SEEPAGE PIT OR Y:'- CURB P.L. M.L.TO P.L.
PITS AND/OR DRAINFIELD @ $3,00 —
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN.. CESSPOOL,DRYWELL C $2.00
HOUSE SEWER CONNECTING TO P.C.NO.
_ PRIVATE DISPOSAL SYSTEM @ $1.00 CO.IMF.NO. ,.-a JOB NO.
WORK TO HOUSElSEWELRBLDG.OR @ $i 00 TRUNK PERMIT N0. ROAD PERMIT NO.
ALTER,REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
SEWER OR DISPOSAL SYSTEM @ $1.00 PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
O`MER'S PERMIT $ 21 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- -
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWLLLING APPROVALS C DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER„
SIGNED THIS DAY OF ig._ NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADDRESS--- SEPTIC TANK,SEEP.PIT(S)
- AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL Cl DRYWELL ❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM THE LEGAL OWUR OF THE ABOVE —
DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS 0
SIGNATURE SEEP.PIT(5) CESSPOOLS
OF PERMITT
VALIDATION ROBERT A. WOOD
m X.O. CASK SUPERVISING MECHANICAL ENGINEER
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