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APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING 14
ADDRESS
Y
JOHN A. LAMBIE, Count Engineer
C
UTT D
GRIFFIN, Supt of Building LOCALITY
NEAREST
FOR APPLICANT TO FILL IN —CROSS ST,
LEGAL 0
DESCRIPTIONLOT NO. f_- OWNER
BLOCK TRACTMAIL
ADDRESS
N&0I_DGS.
SIZE OF LOT
NO,,FBLOT CITY TEL. N0:_
USE OF
BUILDINGSDISTRICT NO. MAP PG PROCESSED BY
GROUP] _BK
CONTRACTOR
ADDRESS CONNECTION DATA
A
CITY RL F
z Tl R NI" DEPTH
J, COUNTY'ATE A HOLE KE' LOWER
FERENCE UPPER
REGISTRATION NO.
NO. DESCRIPTOR OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER C-) $3.00
Ty PE_
E_O�, C_0N N-E CT 10 N LENGTH FROM
SEPTIC TANK,SEEPAGE PIT ORY. CURB PL M.L.TO P.L.
PITS AND/OR DRAINFIELD P $3.00 P.
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN..CESSPOOL, DRYWFLL C $2.00
HOUSE SEWER CONNECTING TO PC.No.
PRIVATE DISPOSAL SYSTEM @ $1.00 CO. IMP. NO. JOB NO,
CONNECT ADDITIONAL BLDG,OR TRUNK PERMIT NO. ROAD PERMIT NO.
--WORK TO HOU SC SEWV.R_._. @ $1.013
ALTER'REPAIRR AANDON HOUSE STATE ENCROACHMENT
SEWEROR DISPOSAL OR
AL"SYSTVII. @ $1.00 PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNER'S PERMIT 2 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 DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THISDAY OP79_..._._. _NEW HOUSE SEWER
OWNER OR CONNECT ADDITION
OWNERS AGENT ADDITIONAL
BUILDING OR WORK F_ '
ADDRESS— SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD
HEREBY ACKNOWLEDGE THAT I 14AVI: READ THIS APPLICATION
A4
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL. [I DRYWELL ❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING —
PLUMBING AND SEWERS, ALTER,REPAIR,SEWER OR
I HEREBY CERTIFY THAI' I AM PROPERLY REGISTERED AND/OR SEWAGE DISPOSAI,SYSTEM
LICENSED AS REQUIRED BY L05 ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND
ABANDON HOUSE SEWER
CALIFORNIA OR TH T I AM-THE LEGAL (qWNER 0 THE ABOVE
DESCRIBED R q'XI. P ERTY,, BACKFILL SEPTIC TANKS ❑
SEEP PIT(S) E] CESSPOOLS El
SIGNATURE
OF PERIITTEE_
ROBERT A. WOOD
'cK. X.01 CASH SUPERVISING MECHANICAL ENGINEER
7 3 3 JAR A NO
y
BAH APPLICATION FOR PERMIT
CE808.9AE®
COUNTY OF LOS ANGELES SEINER--SEWAGE DISPOSAL
.DEPARTMENT OF COUNTY ENGINEER
'BUILDING AND SAFETY DIVISION BUILDING 77
ADDRESS
JOHN A. LAMBIE. County Engineer
CASSATT D. GRIFFIN, Supt of BuDding LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL
DESCRIPTION LOT NO. OWNER
BLOCK r TRACT , MAIC,
�- -1 ADDRESS
NO.OF BLDGS. ¢
SIZE 9F LOT x NOW ON LOT CITY TEL.NO.
USE OF
BUILDINGS DISTRICT N0. GROUP MAP PROCESSED BY
J ..
--— BK PG
CONTRACTOR
ADDRESS N
�t
s a . �'�r" ti CONNECTION DATA
CITY f,.t TE N0. b `' j :' r DEPTH
REGISTRATIOCi NO, t--b GTATE Iyl it£HOLE REFERENCE UPPER
NO. DESCRIPTION OF WORK FEE
LOWER
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3.00 _ -
SEPTIC TANK,SEEPAGE PIT OR TYPE OF CONNECTION LENGTH FROM
PITS ANDi R DRAINFIELD @ $3.00 Y. CURB P.L. M.L.TO P.L. %
OVERFLOW SEEPAGE PIT, DRAINFIEL.D
EXTN.,CESSPOOL,ORYWELL,MANHOLE $2,00
HOUSE SEWER CONNECTING TO v P.C,NO.
PRIVATE DISPOSAL SYSTEM @ $1.00 CO.IMP NO, ,. JOB N6,
CONNECT ADDITIONAL BLDG.OR
WORK TO HOUSE SEWER a $1.09 TRUNKPERMIT NO, ROAD PERMIT N0, _
ALTER. REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
SEWER OR DI5P0$AL SYSTEM a $1.00 PERMIT NO.
a A I d %t, INDUSTRIAL
WASTE APPROVAL
CHARGES
ovmF`.s PERMIT $ -- BC CONNECTION CHARGE FEE
AUTIORIZATION TOTAL FEE <` REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- APPROVALS DATE INSPECTOR'S SIGNATURE
TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER.
SIGNED THIS-------DAY OF 19._._. NEW ROUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
SEPTIC TANK, SEEP,FITS)
ADDRESS AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY CESSPOOL❑ DRYWELL[I
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFYTHAT I AM PROPERLY REGISTERED AND/OR DISCONNECT'PLUG AND -
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR TI I AM THE t9,,GAL DWNER OF THE ABOVE
DESCRIBED RESIDE AL PROPERTY BACKFILL SEPTIC TANKS
SIGNATURE ✓ SEEP,P[T S)�_CESSPOOLS
OF PERMITTEE '
81! VALIDATION ROBERT A.WOOD
gK. Y.Q4 N SUPERXISINQ MECHANICAL,IfiGINEER
if 7 3 4 wrF127 'a 1 A