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D 2 APPLICATION FOR PERMIT
764642
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING _
JOHN A. LAMBIE, County Engineer noDREss _
WILLIAM A. IENSEN, Supt of Building LOCALITY
FOR APPLICANT TO FILL IN �RA053B57_ '��,
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LEGAL
-DESCRIPTION -_LOT NO. _OWNER _
MAIL
BLOCK TRACT2 t ADDRESS
NO. OF SLOGS. •
SIZE OF LOT NOW ON LO7 CITY TEL. NO.
BU IELDINGS DISTRICT NO. GROUP MAP PROC'�SSED BY
K PG
CONTRACTOR 4.yl l--F-L'_L `-!L -L- ( ~•. './ J/ (, �r {,�{,.
ADDRES� k 4r Lo ,�„ � fcI- a— �. -"_✓ ..; CONNECTION DATA
CITY ;� 1 �/V�11?EL. N 4'' � ST—(ON -77 � �� ( DEPTH
C�
-+'—�/ --i��((''��/ +7 ATE MANHOLE REFERENCE ,�/ _
REG TRF4•GPgm+NO�r(f6 „J �/ ❑ COUNTY _ �" 4- f �'�.T'Z�j`y OWER ;
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTI LENGTH FROM r
-HOU —E SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L. (�-' G.
PUBLIC SEWER @ .$5.00 _ .. r0l
SEPTIC TANK,SEEPAGE PIT OR �� P.C.NO. r r
PITS AND/OR DRAINFIELD @ $10.00 CO. IMP.NO. f 2 JOB NO. V
HOU 5E SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM @ $3.00 4 O
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVED EnSEM ENT RECORD.INSTR.NO. DATE
—_ WORK TO HOUSE SEWER @ $3.00
OVERFLOW SEEPAGE P7T.DRAINFIELD +y
EXTN.,CESSPOOL.DRYWELL.MANHOLE@ $5.00 I - HW V.OR ST.WIDENING 4
ALTER,REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL S 6 E @1.00 ""--
_— STATE ENCROACHMENT _
' PERMIT NO.
----- ---- —---- INDUSTRIAL
WASTE APPROVAL f�" ��'Rrl..� �/ ✓�F /, ,,,yam J'�.i
CHARGES
OWNERS PERMIT_ $' 21 Oo -
CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FE I -
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF -1 19_
OWNER OR -"�I f NEW HOUSE SEWER
OWNERS AGENT— `"J .+ rI' j -- --
// f )) BUILDING OR WORK CONNECT ADDITIONAL
.f
ADDRESS--—-z11
D D R E 55.___x__
SEPTIC TANK,SEEP;PIT(5)
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION AND/OR ORAtNFtELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
Li LENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM -
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABOVE DESI: ED RESIDENT I/�}L,/JP`7F,gPPEERT.,YA.,�.
ABANDON HOUSE SEWER
SIGNATURE �? ,l'I/ �^'"
OF PERMITTEE .�. BACKFILL SEPTIC TANKS ❑
- SEEP,PITS) ❑ ,CESSPOOLS ❑
VALIDATION ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
CK� M.O. CASH
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