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:E808 10-63
6A6420 APPLICATION FOR PERMIT ��'� '� -
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION
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A 0 R ESS
JOHN A. LAMBIE. County Engineer z
WILLIAM A. jENSEN, Supt of Building
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LOCALITY
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7NTAWE5T
ST.
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FOR APPLICANT TO FILL IN
C',LEGAL
LOT NO. OWNER
MAIL
BLOCK TRACT ADDRESS
NO, OF EILDG$.
-SIZE OFF LOT TEL. NO.
USE DF
0.1 GROUP I MAP Y
BUILDINGS DISTRICT N K PG PROCESSED B
CONTRACTOR
ADDRESS /' CONNECTION DATA
IY = TEL, NO.? !'# DEPTH
0' STATE
COUNTY MANHOLE REFERENCE f
REGISTRATION NO ❑
V&F FEE TYPE Or CONNECTION
NO.] LENGTH FROM
HOUSE SEWER CONNECTING TO 1 CUR" P.L. M,L,TO P.L.
PUBLIC SEWER @ $5,00
P.C.NO,
CO. IMP NO. F jOS NO.
PITS AND/OR DRA1Nr1ELD $!0,00
sE�WCRc-ON wEcTiwc;--r&
PR IVAI E DISPOSAL SYSTEM $3.00 TRUNK PERMIT NO. ROAD PERMIT NO,
CONNECT ADDITIONAL BLOG,OR tX _AF_F_)_D`AV1T_F_wA,,v i7_EAZ_EWS
A!vE
WORK
TO HOUSE SEWER $3.00
-,PAGE RT,ORAINFJELD
OVERFLOW SEC
T. V I
I:XTN.,CLSSPOOL.DRYWELi.,MANf4QLE @ �.1�4
....... T I.,WIN
0 5 ID WIN
tPEWEIR OR DISPOSA'_SYSTEM @ $3.00
s_- STATE ENCROACHMENT
PERMIT NO. z.
INDUSTRIAL
WASTE APPROVAL
------- CHARGES
OVMER s IT
I F— 2i 00 CONNECTION CHARGE FEE
AUTHORIZATION F TOTAL FEE
.1 HAV AT THIS LATE A CONTRACT WITH THE HEREIN NAMED CON- RFJM_aURSrME:-NT-FE-E
TRACTOR TO
15
CONNECT THE AOVE DESCRISED EXISTING DWELLINGTO THE
P USLIC SEWER. AP R6VALS
DATE INS ZTOR 5 SIGNATURE
SIGNED THISDAY 0F_
OWNER OR
NEW HOUSE SEWER
OWNERS AGENT
-7 CONNECT ADD!
BUILDING OR WORK
------- SEPTIC TANK,SEEP,PIT(5)
HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
I AND/OR DRAINFIELD
AND
STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY"ORDINANCES AND STATE LAWS REGULATING
PLUMB NG AND SE:WFRS, CESSPOOL 0 DRYWELL II
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR A'T r R, li_ZPA I_RS EW ER_0 R
L I FI:N SEDAS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE_015FOSAL SYSTEM.
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
R ESIOE IN. THE ASOVE, DESCRIBED RESIDEN1!A1_ PROFERTYc ABANDON HOUSE SEWER I
OF
SIGNAM
TURF
TE _ BACKFILL SEPTIC TANKS lJ
PERJT ,EIT(S)
SEEP,P CF-ISPOOLS
VALIDATION ROBERT A. WOOD
K. M.Cl: CASH SUPERVISING MECHANICAL ENGINEER