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E808 2 a-59 APPLICATION FC41 PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS
A
C 01111 A. LAMBIE, County Engineer
A BATT D. GRIFFIN, Supt of Building LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL
DESCRIPTION LOT NO.
x"i,'
BLOCK TRACT MAIL
Q ADDRESS
N0.OF BLDGS. 7
'L-
SIZE OF LOT NOW ON LOT CITY TEImn
USE OF
BUILDINGS
DISTRICT NO. GROUT MAP PROCESSED BY
CONTRACTOR
CONNECTION DATA
CITY
TEL.N04C STATION DEPTH
STATE COUNTY
EG MANHOLE REFERENCE UPPER
RASION NO.
LOWER
NO. DESCRIFTION'CrF WORK FEE
HOUSE SEWER CONNECTING'TO
PUBLIC SEWER $3.00
SEPTIC TANK,SEEPAGE PIT OR TYPE OF Z-,DfMKTION LENGTH FROM
CURB P'L M.L.TO P.L.
ITS AND/GR_DRA(NFIELD @ $3.00
OVERFLOW SEEPAGE FIT,DRAINFIELD
EXTNI.,CESSPOOL. DRYWELL (x+ $2.00
HOUSE SEWER CONNECTING TO y P.C.NO.
PRIVATE DISPOSAL SYSTEM p $1.00 Co.!mp. NO. JOB NO.
--tCONNECT ADDITIONAL BLDG,OR IcH�RK TO HOUSE SEWER C $1.00 TRUNK PERMIT NO. ROAD PERMIT NO,
ALTER,REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
SEWER OR DISPOSAL SYSTEM $L00 �
— E RMIT 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 INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS DAY OF NEW HOUSE SEWER
OWNER OR
A�',_�4 ONNECT ADDI TIONAL
OWNERS AGENT
BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PITS)
AND/OR DRAINFiELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL 0 DRYWELL
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. ALTER,REPAIR,SEWER OR
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR SEWAGE DISPOSAL SYSTEM
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE ABANDON HOUSE SEWER
DESCRIBED RESJDENT4AL PROPERTY. BACKFILLSEPTiC TANKS
SIGNATURE SEIP.PIT(5) ❑ CESSPOOLS
OF PERMITT v14,
VALWATI()7- ROBERT A. WOOD
CL U.0, WH SUPERVISING MECHANICAL ENGINEER