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APPLICATION .FOR PERMIT 1
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COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS'
IOHN A. LAMBIE. County Engineer
CASSATT D. GRIFFIN, Supt of Building LOCALITY -
NEAREST a
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL
DESCRIPTION LOT N0. OWNER ;
BLOCK TRACT °� MAIL
` ADDRESS a `fin
NO.OF BLDGS.
SIZE OF LOT
USE OF NOW ON LOT CITY TEL. NO.
BU _
ILDINGS DISTRICT N0. GROUP MAPPROCESSED BY
BK PG I
CONTRACTOR
ADDRESS <5 5; f CONNECTION DATA
CITYv TEL.N0. ^� STATION DEPTH
. STATE MANHOLE REFERENCE UPPER
REGISTRAT40H NO. ��� a COUNTY LOWER
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @0 $3.00 TYPE OF CONNECTION LENGTH FROM
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 @ $2.00
HOUSE SEWER CONNECTING TO P.C.NO.
PRIVATE DISPOSAL SYSTEM @ $1.00 CO.IMP. NO. JOB NO.
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT NO.
WORK TO HOUSE SEWER @ $1.00
ALTER,REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
S WER OR DISPOSAL YSTEM @ $1.00 PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNEWS PERMIT S 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 f INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS DAY OF 19_..._ NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT L BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ElDRYWELL C1
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
C IFORNIA OR THAT,,* AM THE L£ L OWNER OF THE ABOVE
5CRIOED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS ❑
SEEP.PIT(S) ❑ CESSPOOLS
=ERMEII--
E
>r VALIDATION ROBERT A. WOOD
CLL Y.G. CASH, SUPERVISING MECHANICAL.ENGINEER
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E808 8-39 59 -- APPLICATION FOR PERMIT
■
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING a
ADDRESS C' .'
JOHN A. LAMBIE. Countymeet
CASSATT D. GRIFFIN, Supof Bulding LOCALITY
FOR APPLICANT TO FIM. IN NEAREST
CRoss sr,
LEGAL
DESCRIPTION LOT NO. OWNER
BLOCK TRACT MAIL
`.0 ADDRESS_ < _
1
NO.OF BLDGS. ea
SIZE OF LOT NOW ON LOT CITY TEL, NO.
USE OF '
BUILDINGS. .-�, �. - DISTRICT NO. GROUP MAP PROCESSED BY
CONTRACTOR
CONNECTION DATA
CITY TEL.NO. /77
STATION DEPTH
- STATE MANHOLE REFERENCE UPPER
REGISTRATION NO. ! ® COUNTY LOWER
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER Iry $3.00 TYPE OF CONNECTION LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR Y. CURB P,L. M.L.TO P.L.
PITS AND/OR DRAINFIELD @a $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN.,CESSPOOL,DRY WE
@ $2.00
HOUSE SEWER CONNECTING TO - P.C.NO.
PRIVATE DISPOSAL SYSTEM @ $1.00 CO.IMP, NO. JOB N0,
CONNECT ADDITIONAL BLDG.OR
WORK TO HOUSE SEWER $1.00
TRUNK PERMIT N0. ROAD PERMIT NO.
@
ALTER, REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
SEWER OR DIS
SYSTEM @ $L00 PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNER'S PERMIT $ 2 DO CONNECTION CHARGE FEE
AUTHORIZATION I 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 THIS DAY OF 19_____ 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 IHAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ 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
LICE .ZED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CA ORNIA OR THAT 1 ,ATHE LEGA OWNER OF THE ABOVE
DE RIBO RESIDENT1A IROPERTY. BACKFILL SEPTIC TANKS E13S!(' T.l� ,, ,• ,;;�� ." SEEP_.PIT(S) ❑ CESSPOOLS ❑
R I j., +
>r V'ALWATION ROBERT A. WOOD
CL N.C. CASH SUPERVISING MECHANICAL ENGINEER;
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