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DEPAR111IE11TT OF COIIrrrY ENGt>avEFat SEWER—SEWAGE DISPOSAL 1
DIVISION OF BUILDING AND SAFETY ! PERMIT APPLICATION
COUNTY OF LOS ANGiET S
WILLIAM J FOX, COUNTY ENGINEER
BUILDINADDRESSS /j -J
ADDRESS
FOR APPLICANT TO FILL IN LOCALITY //FBUILD ,
NG NEAREST
ADDRESS 7 � 4// -Pi _ CROSS ST
LOCALITY DISTRICT NO SERIAL NO 2- S
PERMITNO
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CROSS ST
RECEIVE B Y� Ready for Inspection DAT I88 ED
OWNER ( It
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CITY '7^ TEL NO
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CONTRACTOR 4
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CO IMP NO �[�7
ADDRESS 7`
JOB NO
CITY a TEL NO U TRUNK PERMIT NO
REGISTRATION NO STATE
f�'�/Q COUNTY ROAD PERMIT NO ����Z0
DESCRLEGIPTION -LOT NO .2 (� ���j STATE ENCROACHMENT
PERMIT NO
BLOCK TRACTyd 3 �l INDUS APPROVAL
TRIAL
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SIZE OF LOT 0 OF BLDGS
G OW ON LOT CHARGES
USE
-BUILDINGS 7-
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NO DESCRIPTION-OF WORK FEE
HOUSE SEWER CONNECTING TO •^,
PUBLICSEWER $ 368 REC�PTNO'3 I r DAT IBY
HOUSE SEWER CONNECTING TO �� `7
PRIVATE DISPOSAL SYSTEM 1 00
CONNECT ADDITIONAL BLDG OR EXC TIO RECORDED
WORK TO HOUSE SEWER 1 00
ALTER OR REPAIR EXISTING NO DATE 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 200 STATION D6PIN _
CESSPOOL–DRYWELL
SPECIAL CONDITIONS ONLY 200 MAN410LE-RE Ea&NGE
UPPER LOWER
TYPE OF CONNECTION LENGTH FROM
Y �`—CURB— P L --M'l TO P L'—`��
OWNERS PERMIT � 1 00 7 .4�
AUTHORIZATION TOTAL. FEE � �/ p �DDGE W//71V
I HAVE THIS DATE CONTRACTED WITH THE HEREIN IED Gd�
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTORS SIGNATURE ATE
DWELLING TO THE PUBLIC SEWER
SIGNED THIS DAY OFA14 19sg NEW HOUSE SEWER t
CONNECT ADDITIONAL
OWNER OR a BUILDING OR WORK
OWNE4S AGENT -SEPTIC TANK SEEP PIT(S)
ADDRESS � Lc o �p AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI CESSPOOL I] ORYWELL
CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER REPAIR SEWEROR
REGULATING PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM o
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED DISCONNECT PLUG AND
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOUSE SEWER \ a
AND STATE OF CALIFORNIA OR THAT 1 AM THE LEGAL OWN
FR OF THE ABOVE_'9ESCRIBEO RESIDENTIAL PROPERTY BACKFILL SEPTIC TANKS `
SIGNATURESEEP PIT(S)[:] CESSPOOLS
OF PERMITTEE
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78A842D
CE808 8 88 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
Zl
JOHN A LAMBIE County Engineer
CASSATT D GRIFFIN Sup t of Building CALITYEAREST
FOR APPLICANT TO FILpL IN R"S STLEGAL
—DESCRIPTION LOT NO � r o�L OWNER
BLOCK TRACT MAIL �J
l7 ADDRESS
NO OF BLDGS
SIZE OF LOT NOW ON LOT CITY 7— TEL NO
USE OF t
BUILDINGS C DISTRICT NO GROUP MAP PRO ES 13Y
BK PG
CONTRACTOR
ADDRESS r CONNECTION DATA
CITY TEL GNO 7_- STATION DEPTH
STATE
L J \ COU TY MANHOLE REFERENCE UPPER
REGISTRATION NO
NO DESCRIPTION OF WORK FEE LOWER
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3 00
SEPTIC TANK SEEPAGE PIT OR TYPE OF CONNECTION LENGTH FROM
PITS AND/OR DRAINFIELD @ $3 00 Y CURB P L M L TO P L
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL MANHOLE @ $2 00
HOUSE SEWER CONNECTING TO P C NO
PRIVATE DISPOSAL SYSTEM @ $1 00 CO IMP NO 0 JOB NO
CONNECT ADDITIONAL BLDG OR �q TRUNK PERMIT NO ROAD PERMIT NO
WORK TO HOUSE SEWER Q $1 00 v
ALTER REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
SEWER OR DISPOSAL SYSTEM $100 PERMIT NO
i
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWM#IS PERfft S 2 00 CONNECTION CHARGE FEE
AUTHORIZATION I TOTh FEE REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON APPROVALS DATE INSPECTOR S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER
SIGNED THIS DAY OF 19_ NEW HOUSE SEWER
OWNER OR Q �� CONNECT ADDITIONAL �' �a.�
OWNERS AGENT �G�"`� BUILDING OR WORK
SEPTIC TANK SEEP PIT(S)
ADDRESS 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 SEWAGE DISPOSAL SYSTEM
IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
LALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDE AL PROP RTY BACKFILL SEPTIC TANKS❑
SIGNATURE ` SEEP PIT(S E3 CESSPOOLS❑
OF PERMITTE
®P VALIDATION ROBERT A WOOD
ON m 0 CAtift SUPERVISING MECHANICAL ENGINEER
[1'.03 7 `0 JLIL 7 i U A 3 0 0 s
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