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768642®60 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION ADDRESS
JOHN A. LAMBIE, County Engineer
WILLIAM A. JENSEN, Supt of Building —LOCALITY
NEAREST
–,
FOR APPLICANT TO FILL IN CRO ss ST—_
LEGAL
DESCRIPTION LOT NO: OWNER
BLOCK TRACT MAI L
ADDRESS
OF BLDGS.
SITE OF LOT W.ON LOT CITY TEL. NO.
USE OF
BUI LDINGS DISTRICT NO. GROUP- MAP PROCESSED BY
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CONTRACTOR Erg PG
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ADDRESS CONNECTION DATA
CITY TEL.NO. STATION DEPTH
STATE MANHOLE REFERENCE •UPPER_
REGISTRATION N HCOUNTY A
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3.00 TYPE OFCONNECTION LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR Y. CURB P.L. M.L.TO P.L.
PIIS AND/OR DRAINFIELD @ $3.00 7�
OVERFLOW SEEPAGE FIT,DRAINFIELD
EXTN. CESSPOOL. DRYWELL @ $2.00
HOUSE SEWER CONNECTING TO C.NO.
PRIVATE DISPOSAL SYSTEM @ $1.00 CO.IMP. NO. JOB NO.
CONNECT ADDITIONAL BLDG.OR
ORK TO HOUSE @ $1.00 TRUNK PERMIT NO. ROAD PERMIT NO. 0
ALTER, REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
1 SEWER OR DISPOSAL SYSTEM C $1.00 PERMIT NO, 0
INDUSTRIAL
WASTE APPROVAL 91
CHARGES
OWNER'S PERMIT s 1 2 00 CONNECTION CHARGE FEE
AUTHORIZATION] TOTAL FEE [_11-1 1 00 REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOWS SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THISDAY OF 19— NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERSAGENT BUILDING OR WORK
ADDRESS__ SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE ROAD THIS APPLICATION
AND STATE T14AT THE ABOVE 15 CORRECT AND AGREE TO COMPLY CESSPOOL P DRYWELL
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. ALTER.REPAIR,
SEWER OR
SEWAGE DISPOSAL AL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/ORDISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM THE LEGAL OWNER OFIHE ABOVE
DESCRIBED RESIDENTIAL PROPERTY.
BACKFILL SEPT6,CCTESNSKS C
SIGNATURE ,"y E]
SEEP.PIT(S) Poo
L❑IS_
OF PERMITTEV
--=VAUDATION ROBERT A. WOOD
CK y
AI.0. CASH SUPERVISING MECHANICAL ENGINEER
"1 7 2 8, 4 fQ1 JAN U 0