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89828.SB APPLICATION FOR'/PERMIT 1
COUNTY OF LOS ANGELES SEINER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION FADDRESSLDING
JOHN A. LAMBIE, County Engineer —
CASSATT D. GRIFFIN, Sup t of Building ALITY
AREST
FOR APPLICANT TO PILI. IN s5 sT.
LEGAL
DESCRIPTION LOT NO. - _a OWNER _ ,___. __........�._,.
.."' .s° :�° -
BLOCK TRACT ' � Jt MAILADDRESS
NO.OF BLDGS.
317E OF LOT i ', - NAW ON LOT CITY TEL. N0.
USE OFI
DISTRICT N0, GROUP MAP PROCESSED BY
BK PG
BUILDINGS
IVCONTRACTOR ye
ADDRESS CONNECTION DATA
CITY TI:_N0, STATION l DEPTH
�— -- STATE MANHOLE REFERENCE9 UPPER
REGISTRATION NO �^ L7 COUNTY
N0. DESC!31P7tC7N OF 4VbRK�_ rE
HOUSE,SEWER CONNECTING TO
PUBLIC SEWER @ $3.00 I TYPE OF CONNECTIO>�-- LENGTH FROM
SEPTIC TANK.SEEPAGE PIT OR Y. CURB P L M.L.TO P.L. AL '>
?ITS AND/OR DRAINFIELD @ 53.00
OVERFLOW SEEPAGE PIT,DRAINFIELD -
EXT,
CESSPOOL.DRYWELL @ $2.00
HOUSE SEWER CONNECTING TO 'P.C.NO.
PRIVATE DISPOSAL SYSTEM @ $1.00 CO.IMF, NO. JOB NO.
CONNECT ADDITIONAL BLDG.OR _TRUNK PERMIT NO. ROAD PERMIT NO.
WORK TO HOUSE SEWER @ $1.00
ALTER, REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
SEWER OR DISPOSAL SYSTEM @ $1.00 PERMIT NO,
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWmR'S PERMIT $ 200 CONNECTION CHARGE FEE
,AUTHORIZATION TOTAL FEE 1 , REIMBURSEMENT FEE - -
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS L DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER. -
SIGNED THIS DAY OF— NEW HOUSE SEWER _ _
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT - �
BUILDING OR WORM(
ADDRESS. SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY _CESSPOOL. Q DRYWELL EJ
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE.DISPOSAL.SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ECT PLUG AND
DISC OONN HOUSE SEWER
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE, ABOVE - -
DESCRIBED RESIDENTIAL PROPERTY, BACKFII.L SEPTIC TANKS ❑
SIGNATURE SEEP.PIT(S) D CESSPOOLS ❑
OF PERMfTTEE_..,_�.__:T
P VAI.DATION ROBERT A. WOOD
Ck. R,u, c+stt SUPERVISING MECHANICAL ENGINEER
C5
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