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10-62
76A"2D APPLICATION FOR PERMIT
COUNTY OF LAS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMEIfT OF COUNTY ENGINEES
BULDING AND SAFETY DIYffiION BUILDING
omir JL L&MM7R ADDRESS 721
WUAJM JL TERM. Sup'[ cd Buflding
LOCALITY
NEAR[1T
FOR APPLICANT TO FILL IN CROSS QT.
D[SCRIFT 10N LOT NO. OWNER
MAIL
BLOCK TRACT ADDREIS
NO. bF ■LDb R.
SRI OF LOT NOW ON LOT CITY TIL. NO.
US[ OF
BUILDING■ DISTRICT NO GROUP MAP P tl'
■K PG
CONTRACTOR
ADDRES8 of f CONNECTION DATA
CITY
O STAT /Ir✓y DEPTH
TIL NO. L
MANHOLE R[F[R[NC[
REGISTRATION NO. COUNTY
No. DESCRIPTION OF WORK FII TYPE of co oN LETI rH F'R
HOUSE S[WIR CO NN[CT1
- NG TO r. lee
Y. R7 P.L M.-L.TO 17
PUBLIC B[WXR 'r $5.00 1•
B[PTIC TANK,B@ O[FST OR CO.IMF.NO. JOS NO.
Pfl"S AND/OR DRAINFIELD � 110.00
HOUSE■EWER CONNECTING TO TRUNK PERMIT NO. ROAD P"MTT NO.
PRIVATE DISPOSAL SYSTEM $3.00
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT I •AMIR I [ 10119 T R[C O RD.INSTR.Ho. DATLKh
WORK TO HOUSZ SEW" i7.DO .y
OVERFLOW S[[PAGZ PIT,DRAIHFI[LD L
[XTN.,CWPOOL,DRYWILL,MANHOL[ 16.00
AL
REPAIR O SA OUS HWY.OR ST.WIDENING
■[W[R OR DISPOSAL SYSTEM $3.00 STATZ[HCROACHMOCT
PERMIT NO.
INDUISTRIAL
WAST[APPROVAL
CHARGIS
OWNEH"8 PESMTT s z 00
CONNECTION CHAROE F[I
AUTHONPLATION TOTAL. FEE
I HAVI AT THIS DATZ A CONTRACT A."
[RIIN NA ZD CON. RZIMSURS[M[NT F[i
TRACTOR TO CONNECT TH[ ABOVE TING DWKLLINGtlTO TH[ PUELIC S APPROVAL DAT[ INSP[ IONATUR[
SIGNEDTHIS DAY OF1
OWNER OR NEW HOUSE SZWLR j{J
OWNERS AO[HT
COIiTJ[LT ADDITIONAL
BUILDING OR WORK
ADDRUD Sof IC TANK,SEM,PIT(6)
1 H[R[SY ACKNOWH
LKDGK THAT I AV[ RKAD THIS APPLICATION AND/OR DRAINFI[LD
AND STAT[ THAT TH[ ABOVE IS CORRCAND AGR[Z TO COMPLY
Y D
WITH ALL COUNTORINANCES IT AND STATI LAWS RZOULATINO
PLU MI,ING AND SEW ERD. C[DSPOOL ❑ DRYWELL ❑
1 HERESY CERTIFY THAT I AM PROPERLY RIOISTERm AND/OR ALTER,RIPAIR,S[W[R OR
LICZNS[D AS R[GUIR[D BY LOS ANOLES COUNTY AND STATI OF BEWAG[DISPOSAL SYSTEM
CALIFQRN IA OR THAT 1 AM TH[ O,AL N[R OF, ND INTEND TO DISCONNECT PLUG AND
R[SID[ IN, THE All R R D L P[RTY. ABANDON SOUS[SEWER
BIGNATUR[ ❑
OF P[RM BACI. IL.ITLS) TANKS
CiLsapooLs
ALIDATION ROBERT A. WOOD
M.o. CASH SUPERVISING MECHANICAL ENGINEER
LAC03620G DEC171 0 D 7.00-