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76A 642D -CE808 -10.71 APPLICATION F PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION F-OLSDS'�'S
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FOR APPLICANT TO FILL IN T
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DESCRIPTION LOT NO OWNER
_ MAIL
BLOCK TRACT L��3 ADDRESS
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SIZE OF LOT NOW ON LOG CITY TEL NO
USE OF
BUILDINGS DISTRICTNO BK p5 GROUP MAP ESSE0 BY
CONTRACTOR _ C4 [` �`J
ADDRESS 9 ��.VJJJ ✓ CONNECTION DATA
„ ST TI N DEPTH
CITYF_j TEL NO 'I
STATE LIC MA HOLE REFERENCE UPPER
LICENSE NO GLASS ---� LOWER
NO DESCRIPTION OF WORK FEE YPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y CURB P L M L TOPIL
PUBLIC SEWER @ $7 00 PC NO
SEPTIC TANK SEEPAGE PIT OR CO IMP NO I..NO
PITS AND/OR DRAINFIELD @ $10 00 }
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO d
PRIVATE DISPOSAL SYSTEM S3 00 O
CONNECT ADDITIONAL BLDG OR AFFIDAVIT WAIVER EASE.ENT RECORD TR NO DATE u
WOR KTO HOUSE SEWER d $300
I OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL 0 S500 -1," 0
- -R-BANDON HOUSE HWY OR ST WIDENINGF-
SEWER M@ $3 00 ` C! STATE ENCROACHMENT W
MANHOLE G -�''� $7 00 PERMIT NO N
INDUSTRIAL Z
WASTE APPROVAL
OWNERS PERMIT S 3 00 CHARGES
AUTHORIZATIONI TOTAL FEE DQ CONNECTION CHARGE FEE
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SE E17 APPROVALS DATE INSPECTOR S SIGNATURE
SIGNED THIS D OF - ^ 19 z_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL
U �� �. BUILDING OR WORK
ADDRESS TT
SEPTIC TANKSEEP PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL 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
LICENSED 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 DESCRIBED RES-ENTIAL PROPERTY ABANDON HOUSE SEWER '
SIGNATURE lL^/ryLyj� BACKFILL SEPTIC T NKS ❑ 2
OF PERMITTEE SEEP PIT(S) SPOOLS jo1�i273
VALIDATION CK M D CASH
Lioo6 ^ o JAN 1710 D 6.00
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76A 61WD -CE808-10-71 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-S WAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESSZNO .LOCALITYNEAREST
FOR APPLICANT TO FILL IN CROSS STLEGAL J� v /ODESCRIPTION LOT NO (/ OWNER /MAIL
BLOCK c TRACT / ADDRESS UpNOOF BLOGSSIZE OF LOT O �.•' NOW ON LOT CITY C TEL /
BU EOF
LUlNGSi',�v W C DISTRICT NO GROUP MAP 8Y/ e , ^J / Ty, BK PSS(CONTRACTOR . ' / IC I,J` / ,Y �O � ///� �A�SED
ADDRESS .2v 7� � `�?`} CONNECTION DATA
A �� J
CITY C/1Dvv� TEL NO �Z STATION ,�66 DEPTH f
L CENSTATESE NO �� bGLASS ✓ 1 MANHOLE REFERENCE./-,,<e/3.,5-7
NO DESCRIPTION OF WORK FEE TYPE OF TION LENGTH FROM
HOUSE SEWER CONNECTING TO Y CURB P L M L TO P L pZ
PUBLIC SEWER @ $7 00 PC NO
SEPTIC TANK SEEPAGE PIT OR
PITS AND/OR DRAINFIELD $1000 CO IMP NO JOB NO ///jjj U
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO / 2
PRIVATE DISPOSAL SYSTEM @ S300 7 O
CONNECT ADDITIONAL BLDG OR AFFIDAVIT I *AIYEp I EASEMEMT RECORD INSTR NO DATE U
WORK TO HOUSE SEWER @ S300
OVERFLOW SEEPAGE PIT DRAINFIELDa
EXTN CESSPOOL DRYWELL @ $500 O
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING I.-
SEWER
SEWER OR DISPOSAL SYSTEM @ $3 00 STATE ENCROACHMENT W
MANHOLE $7 00 PERMIT NO N
INDUSTRIAL Z
WASTE APP ROVAL
OWNERS PERMIT $ 3 00 CHARGES
AUTHORIZATION TOTAL FEE 0 CONNECTION CHARGE FEE
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRI EXISTING DWELLING
TO THE PUBLIC SEW7 APPROVALS DATE INSPTOR S SIGNATURE
SIGNED THIS .I AY_ OF 19" ` S
OWNER OR NEW HOUSE SEWER G�
OWNERS AGEN CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
SEPTIC TANKSEEP PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAI NFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL 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
LICENSEDAS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER F AND INTEND TO DISCONNECT PLUG AND
RESIDE IN THE ABO E DESCRIBED I NT P p RTY ABANDON HOUSE SEWER
SIGNATURE
OF PERMITTEE ( ✓��_RESBAC FI L SEPTIC TANhS ❑
*T7�
SAC
PI (S) 11 CESSPOOLS
VALILALL CK M O CASH
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