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6A642D X APPLICATION FOR PERMIT-�/``779f z
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING ANDSAFETY DIVISION BUILDING
JOHN A. LAMBIE, County Engineer ADDRESS
WILLIAM A. JENSEN, Supt of Building
LOCAL W Lam'-aLL'"F+••C�r�
NEARELT
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL
DESCRIPTION LOT NO. Qif� �. OWNER
7aEe���j
MAIL
BLOCK TRACT Ap DRESSNo
/ �j
SIZE OF LOT NOW ON LOTS) CITY V 1 TEL. NO. T6_C�✓1sy
USE OF DISTRICT NO. GROUP MAP PROCESSED BY
BUILDINGS _ �({J� BK PG /� /�//�
CONTRACTOR 1 6I/ /� 1� (�Y/1
ADDRESS CONNECTION DATA
CITY TEL, NO. STATION DEPTH
STATE UPPER
MANHOLE REFERENCE
REGISTRATION NO. COUNTY LOWER
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L. }
PUBLIC SEWER ® 55.00 P.C.NO. d
SEPTIC TANK.SEEPAGE PIT OR CO.I.P. NO. JOB NO, Q
PITS ANO/OR GRAINFIELD ® SIOOO V
HOUSE SEWER CONNECTING TO THUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM ® $9.00 O
CONNECT DISPOSAL
ADDITIONAL BLDG.OR AFFIDAVIT w[rv[[ [[[[x[xl PECORD. INSTR.NO. GATE
WORK TO HOUSE SEWER ® S3.00 r
OVERFLOW SEEPAGE PIT,DRAINFIELD W
EXTN..CESSPOOL,DRYWELL.MANHOLE® $8 00 d
ALTER,(q!L�HOUSE HWY. OR ST.WIDENING h
SEWER - ---- $3.00STATE ENCROACHMENT
/ PERMIT NO.
INDUSTRIAL
•A �� WASTE AP PROVAL
�L 1 CHARGES
O P RMIT E 2 00
AUTHO ATION TOTAL FEE JI CONNECTION CHARGE FEE '
'IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE '1 I
T FACTO
P TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. APPROVALS DATE INSPEC R}SSI ATU#
SIGNED THIS DAY OF 19_ n ,
OWN ER OR NEW HOUSE SEWER '1
OWNERS AGENT CONNECT ADDITIONAL I/
BUILDING OR WORK V
ADDRESS
SEPTIC TANK,SEEP,PIT(S)
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION pNp/OR GRAINFIELD PSA
AND STATE THAT THE ABOVE ILAND AGREE COMPLY
WITH ALL COUNTY ORDINANCEE S AND
D S STATE LAWS REGULATING 1 • �/
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑ r a
HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED ANO/OR ALTER.REPAIR.SEWER C.R.
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF .6TYVA'�E',OTSPQ$ALJ SYST
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTENA70 DISCONNECT PLUG AND
RESIDE IN, THE A Ip E pESORIBEO RESIDENTIAL PROPERTY. j
ABANDON HOUSE SEWER
SIGNATURE 'd`//C.y'J`P/J//
OF PERM SEE BACK F I LL SEPTIC TANKS
SEEP.PIT I61 ❑ CESSPOOLS ❑
VALIDAT ROBERT A. WOOD
CK. M.O
SUPERVISING MECHANICAL ENGINEER
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L16J.17 .J V v Li Z I CD 5,0 �•-
CAN'CELLLD itT Rl' Y,, ", ; PERMITTEE
:sAsszD,5B 0 -E3 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BDILDINc
JOHN A. LAMBIE. County Engineer ADDHEss
WILLIAM A. JENSEN. Sup'1 o2 Building
LOCALI-
NCAREST
FOR APPLICCANp�T T[OFILL
�IN / CROSS
DESCRIPTION LOT NO. %%�—//✓✓}}////-- IV/1li- (_i('/q` OWNER [.V JJJIII�.+�✓liL
M,IL
BLOCK TRACT ADDRE65
NO. OF BLOCS.
SIZE OF LOT NOW ON LOT CITY TEL. NO,
U6E OF .. !hy
777T� AP PROCESSED BY
CONTRACTOR
ADDRESS ^A%/�✓�--� CONNECTION DATAV
CITY TEL. NO. froQ / ✓• STATION
DEPTH
ATEUPPER
REGISTRATION NO. E3COUNTV MANHOLE REFERENCE (OWER
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L.
PUBLIC SEWER ® $5.00 P.C.No. a
SEPTIC TANK.SEEPAGE PIT OR CO.IMP. NO. JOB NO. O
PITS ANO/OR DRAINFIELD ® 510.00
HOUSESEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO,
PRIVATE DISPOSAL SYSTEM 0 53,00 O
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT wqv[[ 4[[xaxi REI N
CORD. STR.NO. DATE
WORK TO HOUSE SEWER If $3.00 r
OVERFLOW SEEPAGE PIT.GRAINFIELD W
E%TN,.CESSPOOL..RYWELL,MA NPO LE@ $5.00 a
ALTER.REPSIZ�[`�ldHx!lOPHOUSE HWY.OR ST.WIDENING IA
SEWERO M ® 53.. S00 STATE ENCROACHMENT
' Q PERMIT NO,
INDUSTRIAL
WASTE APPROVAL
OWNERS I PERMIT IS 21 00 CHARGES
AUTHORIZATION I TOTAL FEE CONNECTION CHARGE FEE
-I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. APPROVALS DATE INSPECTOR'SSIGNATURE
SIGNED THIS DAY OF 19_
OWNEROR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
SEPTIC TANK SEEP.PIT 15)
HEREBY ACKNOWLEDGE THAT HAVE HEAD THIS APPLICATION pryO/OR DRAINFIELD
AND STATE THAT THE ABOVE ICORRECT AND AGREE COMPLY
WITH ALL COUNT Y
OUNTV ORDINANCES
S AND STATE LAWS REE GULATING
PLUMBING AND SEWERS. CE65POOL ❑ ORYW ELL ❑
IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER.REPAIR.5 EWER 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 0.80V DESCflIBEO flFTS NTIgBP PERTY ABANDON HOUSE SEWER
SIGNATURE
OF PERMITTEELC✓✓V✓�i- A /. ''ll//�I�J((a//CVJ BACKFILL SEPTIC TANKS ❑
❑
SEEP.PIT(S) [I CESSPOOLS
VALIDATION ROBERT WOOD
CK. M.0. CASH SUPERVISING MECHANICAL ENGINEER
L,Qa6 o 1 3�*S DEC 9 1 0 D 5.00-