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5 83 ti-55 APPLICATION FOR PERMIT
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DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Department of County Engineer
County OI LOS Angeles BUILDING ^• p --
JOHN A. LAMBIE, COUNTY ENGINEER _ADDRESS_ �41 1° ft✓rte Cj C 'ds f.
CASSATT D. GRIFFIN, SUPT OF BUILDING
LOCALITY
_
FOR APPLICANT TO FILL IN doss sT
--LEGAL }, .�4r� a .A ��— C* q —
_D£SCRIPT[ON LOT NO I OWNER __ELLaCF .r '
MAI L
BLOCK 'TRACT d j - ADDRESS
e✓ N.o.OF BL➢GS. -
SIZE OF LOT (>7 3 �'. NOW ON LOT v 1rej. CITY t.. a/ - TEL. NO. j—
USE OF
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DISTRICT N.O. 1, GROUP MAP
BK PG
CONTRACTOR
CONNECTION DATA
ADDRESSls; y --- -- -- --- - - - --
CITY r' - _SION ,� S' DEPTH - —
� .s, l` TEL. NO. TAT
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° MANHOLE REFERENCE _
STATE _ � 4, I S•� LOWER
REGISTRATION�N0. � y �- �' [] COUNTY -- -- .- -- -------
No. DESCRIPTICIN OF WORK FEE T --- ------ -- --
-------._'-`-.- -- TYPE OF CONNECTION LENGTH FROM l'
HOUSE SEWER CONNECTING 70 -
j .__--- @ $3.50 _� Y. CURB_ _ ,P.L, M.L. TO P.L.
PUBLIC SEWER �
SEPTIC"TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD Q $3,00 _ ---
OVERFLOW SEEPAGE PIT DRAINFIELD P C R0, A
FXTN ,CESSPOOL,DPYWELL,MANHOLE rr, $2.00, I CO. IMP. NO,
HOUSE SEWER CONNECTING TO Ir -
PRIVATE DISPOSAL SYSTEM $1.00 ( j TRUNK PERMIT NO. ROAD PERMIT NO.
CONNECT ADDITIONAL BLDG OR STATE ENCROACHMENT
WORK TO HOUSE SEWER_ _CA,_.$-1.00 1
PERMIT NO,
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
--.f SEWER OR DISPOSAL SYSTEM c;. S tA0 �_- WASTE APPROVAL
I CHARGES
CONNECTION CHARGE FEE
OWNBR"S PERMIT g I 1 00 — - - --
AUTHORIZATION TOTAL FEF, � REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMEDcoN- APPROVALS i DATE INSPECTOR'S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
----_-- -`----------_.----------__---_---
TO THE PUBLIC SEWER. NEW HOUSE SEWER
SIGNED THIS DAY OF 19.^ CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK
OWNERS AGENT as t' _..��� SEPTIC TANK.SEEP.PIT(S)
ADORES S _ ANDiOR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE: READ THIS APPLICATION --CESSPOOLL7 DRYWEL.LO---�-- '
AND STATE THAT THE ABOVE IS CORRECT.AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS, SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DI5CONNECT�Pt.UG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE ABANDON HOUSE SEWER
DESCRIBED RESIDIENT1AL PROPERTY. BACKFILL SEPTIC TANKS{]
SIGNATURE j �' SEEP.PIT(5)0 CESSPOOLS❑
OF PERMITTEE �` t of =� -- -- —
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JOHN A. LAMBIE,COUNTY ENGINEER VALIDATION ROBERT A.WOOD, CHIEF PLBG. INSPECTOR
CASH
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