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76A 6ato APPLICATION FOR PERMIT
TSA s
P COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER ^ -
BUILDING AND SAFETY DIVISION F BwLa,Nc a rj
JOHN A. LAMBIE. COUNTY ENGINEER ILADDRESS X
COLEMAN W. JENKINS. SUPT. OF BUILDING
LOCALITY
FOR APPLICANT TO FILL IN NEAREST
(PRINT OR TYPE ONLY) CRo55 ST. �I
LEGAL
DESCRIPTION LOTNO. A. OWNER
MAIL O
BLOCK TRACT y / ADDRESS Y✓"
NO. OF BLDGS. y J
SI2E OF LOT NOW ON LOT CITY TEL. NO. �O
USE OF
BUILDINGS DISTRICT NO. GflOUP CLA55 BK MdP pq OCE55E0 BT
p5
CONTRACTOR ,y/ ytL-.pP�o r� � �' �Q6 \
ADDRESS /� "" ,E CONNECTION DATA
c1iY TEL.. NO.� J r' STATION DEPTH
J i-
STA �Y / LIC T9 MANHOLE REFERENCE UPPER
LI GNSE NO. �j (G CLA55 '23 LOWER
NO. D RI PTION OF RK FEE TYPE OF CONNECTION LENGTH FROM
MOU E SEWER CONN INC TO Y. CURB P.L. M.L.TO P.L.
PUBLIC SEWER 53.OD
SEPTIC LANK,SEEPAGE PIT OR CO.IMP,NO. JOB NO.
PITS ANO/OR DRAINFIELD SIO.00
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. d
PRIVATE DISPOSAL SYSTEM $3.00 O
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAV" z[R[ RECORD.INSTR.NO. DATE
WORK TO HOUSE SEWER 33.00 U
OVERFLOW SEEPAGE PIT.GRAINFIELD O!
EXTN..CE SSPOOL.DRIWELL.MANHOLE a 55.00 HWY.OR ST.WIDENING O
ALTER,REPAIR OR ABANDON HOUSE F
SEWER OR DISPOSAL SYSTEM ® S3.00 STATE ENCROACHMENT W
PERMIT NO. d
INDUSTRIAL N
WASTE APPROVAL Z_
CHARGES
OWNERS PERMITs DD
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL. FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS
TO THE PUBLIC SEWER. DATE IN TOR'S SIGlkTURE
SIGNED THIS AY O 19_
OWNER OR NEW HOUSE SEWER 7
OWNERS AGENT
CONNECT ADDITIONAL
BUILDING OR WORN
ADDRESS
I HEREBY ACKNOWLEDGE THAT 1 NAVE READ THIS APPLICATION SEPTIC TANK,SEEP.PIT(S)
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY AND/OR DRAINFIELD
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ❑
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR ALTER,REPAIR.SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY D STATE OF SEWAGE DISPOSAL SYST EM
CA LIFORNII OR THAT 1 AM THE LEGAL O R O PINTS ND TO
C EO RE E ROF Y,
RESIDE IN, THE 4 OISCONN ECT PLUG ANO
ABANDON HOUSE SEWER
SIGNATURE
PERE ` BACKFILL SEPTIC TANKS ❑
OF PERMITTEE ❑
P.PIT 151 ❑ CESSPOOLS
/ 0ALIDATION JACK R. ALLEN
CK. M.O. CASH SUPERVISING MECHANICAL ENGINEER
I
Lilo 41 4 N a°a11 1 0 D 600- v
1 i
7610-fi3
A64 APPLICATI FOR PER IT
8 0
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION
JOHN A, LAMBIE, County Engineer ADDRSss DG QUC GV
WILLIAM A. JENSEN, Sup't of Building
LOCALITY
NEAREST
FOA APPLICANT TO FILL IN CROSS ST.
LEGALf ✓/ /)
DESCRIPTION LOT NO. / `, OWNER
MAIL T
BLOCK TRACT ADDRESS - [.._
CL AIL&A
NO. OF BLDGS.
SIZE OF LOT NOW ON LOT CITY e ( _TEL. NO.
USE OF-
BUILDING DISTRICT NO, GROUPI MAP PROCESSED BY
BK
PG
CONT O13 N FD 5
ADDRESS / �'�/" CONNECTION DATA
STATION y[� DEPTH .�
CITY TEL. O/
A ATE MANHOLE REFERENCE R
REGISTRATION NO. .1 COUNTY (f LOWER
NO. DESCRIPTION OF WORK FEE TYPE OF NE.)10N LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L.
PUBLIC SEWER 0 S5.00
P.C.NO. 1
SEPTIC TANK,SEEPAGE PIT OR O
PITS AN./CR GRAINFIELD 310.00 CO.IMP. NO. _ 2—_ JOS NO.
HOU5E SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT N0 doll "
PRIVATE DISPOSAL SYSTEM 53.00 C
CONNECT ADDITIONAL BLDG.OR AFFIOq VIT [rv,ER [xi RECORD.INSTR.NO. GATE
WORK TO HOUSE SEWER ® 33.00 / T 0
OVERFLOW SEEPAGE PIT.DRAINFIELD 1 , W
E%TN.,CESSPOOL.DRYWELL.MANHOLE 0 $5.00 -J a
ALTER,REPAIR OR ABANDON HOUSE HWY' NI G N
SEWER OR DISPOSAL SYSTEM ® S3,00 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT s z o0
AMHORIZATION 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 E)IST IN
DWELLING
TO THE PUBLIC SEWER. APPROVALS I DATE INBPECTOR'B BIGNATUflE
SIGNED THIS DAY O Ig_ S�/I_ µ�
OWNER OR NEW HOUSE SEWEq ��'/j�.S " r``
OWNERS AGENT CONNECT ADDITION AL L
BUILDING OR WORK
ADDRESS
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION SEPTIC TANK.BEEP,PIT ISI
AND/Oq DRgINFIELD
AND
STATE THAT THE ABOVE IS CORRECT AND AGREECOMPLY
WITH COUNTY ORDINANCES ANO STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYW ELL ❑
I HEREBY CERTIFY AT 1 AM PROPERLY REGISTER O ANO/ORL�LTER.R�PAIR,SEWER OR
LICENSED AS RE RED BY LOS ANGLES COUNTY AN 5TATE OF ISPOSAL SYSTEM
GLIFORN4 OR HAT M THE LEGAL O R ./AN INTEND TO CT PLUG ANDRESIDE IN, T 4BOV DESC RIMED RE D TIA RO ERTY. HOUSE SEWERSIOF PE RE SEPTIC TANKSOF PERMIT 5) ❑ CESSPOOLS ❑
K.
VALIDATION ROBERT A. WOOD
M.D. CASH SUPERVISING MECHANICAL ENGINEER
jr,,o 0 3 0 5`0 PH p 1 0 D 7.0 0
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