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E8 13-ss APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A• LAMBIE, County Engineer ADDRESS
CPMATT D. GRIFFIN, Supt o4 Bund ng LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL _ 4
DESCRIPTION LOT N0, >-= OWNER
BLOCK TRACT MAIL —
ADDRESS
140.OF BLDGS.
SIZE OF LOT . ',�r NOW ON LOT s CITY TEL. N0.
USE
BUILDINGS DDISTRICT NO. GROUP MAP PROCESSED BY
K PG r
CONTRACTOR r_ y
ADDRESS CONNECTION DATA
CITY TEL.NO. STATION DEPTH r
_if
❑ STATE MANHOLE REFERENCEr -, LOWER'
REGISTRATION N4. [] COUNTY }
N4. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER ?° $3.00 J TYPE OF CONNECTIO P.--._ LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR Y. CURB L. • M,L.TO P.L.
PITS AND/OR DRAINFIELD @ $3,00
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN..CESSPOOL.DRYWELL @ $2,00
HOUSE SEWER CONNECTING TOP.C.NO,
�
PRIVATE DISPOSAL SYSTEM @ $1.00 CO.IMP.N4. �� i ,; JOB N0.
CONNECT ADDITIONAL BLDG.OR
WORK TO HOUSE SEWER SLOO
TRUNK PERMIT N0. ROAD PERMIT N0.
C�?
ALTER.REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
SEWER OR DISPOSAL SYSTEM $1.00 PERMITNO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNER'S PERNUT 2 00 CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE ..P. REIMBURSEMENT FEE
I 14AVE AT DATE A CONTRACT WITH THENAMED CON.
TRACTOR TO CLONNECT THE ABOVE DESCRIBED EXIISTI�NG DWELLING APPROVALS DATE INSPECTOR'S SIGNA7RE
TO THE PUBLIC SEWER.
SIGNED THIS DAY OF 19— NEW HOUSE SEWER
OWNER OR _..-.� CONNECT ADDITIONAL
OWNERS AGENT I'^- ....___ BUILDING OR WORK
ADDRESS.- SEPTIC TANK,SEEP.PIT(S)
ANA/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION.AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL. ❑ DRYWELL ❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ELTER,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 OWNER OF THE ABOVE
DESCRIBED RESIDENTIAL PROPERTY. a BACKFILL SEPTIC TANKS ❑
SIGNATURE {
SEEP,PIT(3) ❑ CESSPOOLS ❑
OF PERMITTEE I J
3r V'ALiDATION ROBERT A. WOOD
CK. X.o, CASH SUPERVISING MECHANICAL ENGINEER
,`3 is r 3 ..