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76A6420 APPLICATION FOR PERMIT
76A 642
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION B
UILDING
O �f O ,� u W v o l
JOHN A, LAMBIE• County Engineer
WILLIAM A. JENSEN, Supt of Building CALITY ' c
FOR APPLICANT TO FILL IN OSS ST. e c'
LEGAL
DESCRIPTION LOT NO. OWNER
BLOCK TRACT �Q 2(� MAIL
ADDRESS Q ��/ O �►` �� UA n
NO.OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF
BUILDINGS DISTRICT NO. GROUP I MAP PR
BK PC OCESSED BY
N14-g
/ V —
CONTRACTOR V
ADDRESS S'd Lv �/`7N /'t /D` CONNECTION DATA
CITY cju /./I9 c' TEL.NO. // "/ S Z STATION DEPTH
REGISTRATION N0. ,� / I COUNTY MANHOLE REFERENCE UPPER
LOWER
NO. 1 DESCRIPTION OF WORK FEE J
HOUSE SEWER CONNECTING TO � ,, / �+ '
lr
PUBLIC SEWER @ $3.00 TYPE OF C NNECN LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR Y. CURB P.L. M.L.TO P.L.
PITS AND/OR DRAINFIELD @ S3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD d
EXTN..CESSPOOL.DRYWELL @ $2.00
HOUSE SEWER CONNECTING TO P.C.NO. 0
PRIVATE DISPOSAL SYSTEM @ $1.00 CO.IMP. NO. JOB NO. V
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT N0. ROAD PERMIT N0.
WORK TO HOUSE SEWER @ $1.00 0
SEWER OR DpISP SAL SYSTEM HOUSE @ $1.00 STATE ENCROACHMENT !-
PERMIT NO. V
P. . C — y INDUSTRIAL a
WASTE APPROVAL to
wwTT
CHARGES z
O��iiff♦�MR'S PEiMT S 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE 61v REIMBURSEMENT FEE
I HAVE AT DATE A CONTRACT WITH THE CON-
TRACTOR TO CIONNECT THE ABOVE DESCRIBED EXISTI(NGAMED DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS DAY OF 19— NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PITS)
AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL Cl
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIAL PROP TY BACKFILL SEPTIC TANKS ❑
SIGNATURE L_ ��,�.•�- SEEP.PIT(S) ❑ CESSPOOLS
OF PERMITTE
RX.ATION ROBERT WOOD
0. cAsx SUPERVISING MECHANICAL.ENGINEER
UC-060 5 5 %--&' D"c13 1 0 D 3.00 �'
DEPARTMFINT OF COUNTY EN(3M3M SEWER-SEWAGE DISPOSAL, 1
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER BUILDING
ADDRESS
FOR APPLICANT TO FILL IN LOCALITY
BUILDING k fE e f NEAREST
ADDRESS r 4r d� i" -'� •"' CROSS SL
LOCALITY ) if *' DISTRICT NO. I Ready for Inspection I PERMIT NO. c
NEAREST S
CROSS ST
RECEIVED BY DATE ISSUED BY DATE
OWNER ? �
MAIL I T 1 r USE ZONE I OCCUPANCY BK MAP PG
ADDRESS !L` U r/E `' d� "t7
CITY 's .�.:;f� r' ,. TEL.MO '^`;, 1' f SR
CONTRACTOR CO.IMP.NO.
ADDRESS JOB NO.
CITY TEL.NO. TRUNK PERMIT NO.
STATE
REGISTRATION NO. COUNTY ROAD PERMIT NO.
LEGAL
DESCRIPTION LOT NO. STATE ENCROACHMENT
j i. PERMIT NO.
BLOCK TRACT f 0 ,:, INDUSTRIAL
NO.OF S f WASTE APPROVAL
SIZE OF LOT (� )k ,� NOW ON LOT / CHARGES
USE OF
BUILDINGSCONNECTION CHARGE FEE
NO. DESCRIPTION OF ORK FEE
HOUSE SEWER CONNECTINO TOREIMBURSEMENT FEE
PUBLIC SEWER 0 $ 3.50
_
HOUSE SEWER CONNECTING TO RECEIPT NO. DATE BY
_ PRIVATE DISPOSAL SYSTEM I.CO
CONNECT ADDITIONAL BLD6.OR EXCEPTION RECORDED
WORK TO HOUSE SEWER 1.00
— ALTER OR REPAIR EXISTING NO. DATE I BY
SEWER OR DISPOSAL SYSTEM 1.00
DISCONNECT AND ABANDON SEWER
_ AND/OR DISPOSAL SYSTEM 1.00 CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR
_ PITS AND/OR DRAINFIELD 2.00 STATION DEPTH
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 2.00 MANHOLE REFERENCE
UPPER LOWER
TYPE OF CONNECTION LENGTH FROM
OWNERS PERMIT $ 1 00 Y. CURB P.L. M.L.TO P.L.
AUTHORIZATION I TOTAL FEE - ;y
1 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
SIGNED THIS_.-_._._...___DAY OF___ 19 NEW HOUSE SEWER
'Z
OWNER OR -t Jar CONNECT ADDITIONAL
OWNERS AGENT-:> tJ__ `�"--�{''-''' BUILDING OR WORK
`;: f �, SEPTIC TANK,SEEP.PIT(S)
ADDRESS_............-' •---•--"-- - - �._._.a-----•et- - - -- AMD/OR DRAINFIELD
CAITHEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLI- CESSPOOL Ej DRYWELL
IONAND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER,REPAIR,SEWER OR
REGULATING PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY DISCONNECT PLUG AND
AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN. ABANDON HOUSE SEWER
ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS F]
SIGNATURE ti { jj tt SEEP.PIT(S)[3 CESSPOOLS
OF PERMITTEE-._ -._.._ _L_. —_ 1Z�.f.._._____..__-_-------..
76A6421) S&E 663 4/54