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DEPARTMENT OF COUNTY ENGINEER SEWER-SEWAGE DISPOSAL 1
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
WILLIAM J FOX, COUNTY ENGINEER BUILDING / ��/�fS�
CASSATT D GRIFFIN SUP T OF BUILDING ADDRESS (4
FOR APPLICANT TO FILL IN LOCALITYBUILDING NEAREST
ADDRESS -CROSS ST
LOCALITY 7' /7//— 7��`r� DISTRIC�Tj NO SERIAL NO PERMIT
PERMIT NO C
NEAREST /RS`_U11RS I��WdDDeUr� ' A �C5 5�Z J
CROSS ST L
?)RECEIVED//BY Ready for Inspection DATE ISSUED
MAIL 131 . B Ult mr'l ST"�f� -eW 3-3/ _
ADDRESS J19 /'_
USE ZONE I OCCUPANCY MAP
BK PG
CITY TEL NO
CONTRACTORCHARGES REIMBURSEMENT FEE
ADDRESS REQUIRED
CIT4��jjf�& ,e`1rKTELNOA � ,12 NOT REQUIRED
.CC JOB NO CONNECTION CHARGE FEE
STATE
REGISTRATION NO Q�� oetrxrv— CO IMP NO AIR
LEGALh ` RECEIPT NO DATE I BY
/Y
DESCRIPTION LOT NO S a.7 �——
BLOCK TRACT 6 S(o WAIVER FOR RECORDING
SIZE OF LOT SO K /gS NO OF BL T RECEIPT NO I DATE I BY
NOW ON LOT
USE OF
BUILDINGS 75,95/10ENG,E TRUNK PERMIT NO
NO DESCRIPTION OF WORK FEE
PUHUSE SEWER BLIC SEWERCONNECTING TO @ $ 3 50 5(, ROAD PERMIT NO ?3L/
HOUSE SEWER CONNECTING TO STATE ENCROACHMENT
PRIVATE DISPOSAL SYSTEM 1 00 PERMIT NO
CONNECT ADDITIONAL BLDG OR INDUSTRIAL
WORK TO HOUSE SEWER 1 00 WASTE APPROVAL
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM 1 00 CONNECTION DATA
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 100
SEPTIC TANK SEEPAGE PIT OR STATION 'g Jr DEPTH
PITS AND/OR DRAINFIELD 200 MANHOLE RE(/FRENCE
CESSPOOL—DRYWELL UPPER ) � 5 �/) )— LOWER----'
SPECIAL CONDITIONS ONLY 200 I� TYPE OF CONNECTION LENGTH FROM 1 L I
Y _ _ CURB P L M L TO P L JJ
OWNERS PERMIT $ I 00 -
AUTHORIZATION TOTAL FEE V
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR S SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER I �J
SIGNED THIS C DAY OF 19Fj NEW HOUSE SEWERS
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT 6, I&V.M" � BUILDING OR WORK
ADDRESS � � �3dy� �y�� �UA, t AND/OR DRAINFIELD TANK SEEP PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI CESSPOOL DRYWELL
CATICN AND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER REPAIRSEWER
REGULAT NG PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT t AM PROPERLY REGISTERED DISCONNECT PLUG AND
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOUSE SEWER
AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN
ER OF THE ABO
�sV
y�E DESCRIBED RESIDENTIAL PROPERTY y BACKFILL SEPTIC TANKS E] I /�
SIGNATURE J�" " ay�� L��a��� SEEP PIT(S)� CESSPOOLS 2,
OF PERMITTEE 1
16A642D 663 12/12