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76;42081 APPLICATION F PERMIT
COUNTY OF LOS ANGELES SEWER SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER y
BUILDING AND SAFETY Engineer
ABU
DDRESS
4
WILLIAM A J�ENSENCSuptt of Building �+
_ LOCALITY v
NEAREST
FOR APPLICANT TO FILL IN CR2SS ST
LEGAL OWNER
DESCRIPTION LOT NO Z
BLOCK TRACT MAIL
ADDRESS
SIZE OF LOT Z NO OF BLDGS
OW ON LOT CITY TEL NO
USE OF CNS DISTRICT NO GROUP YAP PROC D BY
BUILDINGS
�. BK PG
CONTRACTOR J- r "Ar
" 2-do
ADDRESS CONNE( N DATA
CITY TEL NO a d N DE I
REGISTRATION NO STATE ANHOLE REFEREN
COUNTY LOWER
No I DESCRIPTIO OF WORK FEE
PUBLIC SEWER
CONNECTING TO $y 00
SEPTIC TgNK SEEPAGE PIT OR ' TYPE OF CONNECTION LENGTH FROM /
PITS AND/OR DRAINFIELD @ $300 Y CURB P L Y L TOP L
OVERFLOW SEEPAGE PIT DRAINFIELD }
EXTN CESSPOOL DRTWELL @ 3200 4.
PRIVATE DISPOSAL SYSTEM TO S1 00 CO IMP NO JOB NOD 0
CONNECT ADDITIONAL BLDG OR TRUNK PERMIT NO ROAD PERMIT NO OC
WORK TO HOUSE SEWER $100
SEWER OR DISPOSAL SYSTEM HOUSE $1 00 STATPERME
NO
CROACHMENT Q
INDUSTRIAL LU91.
WASTE APPROVAL N
CHARGES ?
Q S PERMIT $ CONNECTION CHARGE FEE
AUTHORIZATION r 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 19_ NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERSAGENT7;��- BUILDING OR WORK
ADDRES¢ 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 ❑ DRYWELL
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWER OR
PLUMBING AND SEWERS
1 HEREBY CERTIFY THAT I AY PROPERLY REGISTERED AND/OR SEWAGE DISPOSAL SYSTE11
DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON MOUSE SEWER
CALIFORNIA OR THAT 1 M THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTI OPERTY SEEPFILL PIT(S)P❑ CESSPANKS ❑
SIGNATURE
OF PERMITTEF J
VALIDROBERT A WOOD
0
CK ■ o WR SUPERVISING MECHANICAL 8NGINEER
LAC01 6 2 VA APR 2 4 1 1 D 2500 a
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