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T6A642D APPLICATION FOR PERMIT
6A642
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County Engineer ADDRESS
WILLIAM A. JENSEN. Supt of Building
LOCALITY
NEAREST
FOR APPLICANT TO FIL -IN `ROSS 5T.
LEGpL )
DESCRIPTION LOT NOY , J� !l OWNER
MAIL
BLOCK TRACT � S / ?r�y AppRE55 Ip
N. OF BLOCS. _C
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF
BUILDINGS ` DISTRICT NO.1 GROUP MAP PROCESS OST
i_ � BK PG
CONTRACTOR
ADDRESS ,C 2� !mac/ /' p$ STATION CONNECTION DATA
CITY GTEL. NO.� I �b O / ;] L "I DEPTH J 1
REGISTRATION NO. O ! O COUNTY MANHOLE REFERENCE r_ .F %J`' // LOQ WWEERR
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION 'LENG'TMF M
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.
PU BLIC SEW ER a 35.00 P.C.NO. d
SEPTIC TANK.SEEPAGE PIT OR CO.IMP. NO. JOB NO. O
PITS AND/OR DRAINFIELD @ 510.00 V
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. /
PRIVATE DISPOSAL SYSTEM ® 53.00 K
CONNECT ADDITIONAL BLDG.OR AFFID IT w[rvu [s[R[xT RECORD.INSTR.NO. / DATE O
WORK TO HOUSE SEWER @ S3.00 ',� v
OVERFLOW SEEPAGE PIT.DRAINFIELD �.
E%TN,.CE55POOL.D RYW ELL,MA NH OLE® 56.00 HWY. OR BT,WIDENING �! a
ALTER-RGRHR'OR ABANDON HOUSE _ [q
SEWEROR"LLSEOSA Y.
53.00 �J UJ STATE ENCROACHMENT Z
f- PERMIT NO.
INDUSTR Il!yy44
WASTE_PROVAL
CHARGES
OWNER'SPER ( 2 ao'
AUTHORIZATION TOT L FEE � M Z CONNECTION CHARGE FEE
'I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EX(STINP DWELLING APPROVALS
TO THE PUBLIC S ER ! DATE INSPECTOR'S SIGNATURE
SIGNED THIS OA OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL
6 BUILDING OR WORK
pOORE55
SEPTIC TANK,SEEP,PIT(S)
HEREBY ACKNOWLEDGE THAT 1 HA YE READ THIS APPLICATION gryO/OR GRAINFIELD
AN DSTHAT THE ABOVE 15 CORRECT AND AGR
WITHALL EE E COMPLY
WITH COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBINGNG AND SEWER$. CESSPOOL ❑ pRV WELL ❑
HEREBY CERTIFY THAT I AM .PROPERLY REGISTERED AND/OR ALTER.REPAIR.SEWER OR
LICENSEp AS REQUIRED BY LOS ANGLE COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL 9NER OF. AND INTEND TO DISCONNECT PLUG ANO
RESIDE IN, THE ABOVE DESCRI R ENTIAL PROPERTY. ABANDON HORSE SEW ER
SIGNATURE
OF pFERMITTEE�_ BACKFILL SEPTIC TANKS ❑ 1 K
SEEP.AITISI ❑ CESSPOOLS ❑
VALIDATION—\ ROBERT A. WOOD
(Q
CK. M.O. CASH2
L� /pi q -✓ /IZ���� SUPERVISING MECHANICAL ENGINEER
f ✓V Llilr���y�
Gtr AJ.�r L /
07 ri Q 3 V' 21i1 0 D 1 0..0 0- r:
•mil-'C .
DEPARTMENT OF COUNTY ENGINEER, SEWER-SEWAGE DISPOSAL p
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION g
COUNTY OF LOS ANGELES
WILLIAM J. FOX; COUNTY ENGINEER NG
ADORE
ADDRESS
FOR APPLICA T TO FILL I LOCALITY
B
U
IL
D
'
NG/�� � _ CNEAREST
ROSS ST. T
ADDKESS /C6•LgQ C�
LOCALITY i I - DISTRICT NO. SERIAL N0. PERMIT N0.
NEAREST ✓ A �Q 7? S
CROSS ST. n� g�E) Y Ready for Inspection `DTA'2 ISSU ED
OWNER ' GY S
MAIL /
ADDRESS USE 20NE OCCUPANCY -MAP—
y/� BK PG
CITY �f' � TEI.NO. ^ l ,rr L+ / 2 Q.
CONTRACTOR / �/•ii/.eCr! 'C O`.IMP. N0. 12 GZ_V J
ADDRESS 6 6 f i/}} � JOB.NO. /U
CITY f I TELAO. /�J T TRUNK PERMIT N0.
ST
REGISTRATION NO. / (� '"' '� STATE
COUNTV :.•:-2�
ROAD PERMIT NO. 6
LEGAL G(I,'cf'�y' eT •7j STATE ENCROACHMENT
DESCRIPTION LOT N0. `2D PERMIT NO.
BLOCK TRACT fSSIOIV � LG INDUS RIALWASTAPPROVAL
SIZE OF LOT /�' NO.OF BLDGS. j— f �_—
rp NOWWJON/LOOT_ CHARGE
USE OF T�//e /A� /1. "Y�/C'Y_+n G2 QiC� 1
BUILDINGS .1 /H/ a. CONNECTION CHARGE FE
NO. DESCRIPTION OF HOUSE WORK EE �� REIMBURSEMENT FEE
7/-PUBLIC SEWERROUSE SEWER CONNECTING TO ® >; 350 �^ RECEIPT N0. I/ DATE I BY
PRIVATE DISPOSAL SYSTEM IAO
CONNECT ADDITIONAL BLDG.OR ]EXCEPTION RFTCORDED
WORK TO HOUSE SEWER 1.00
ALTER OR REPAIR EXISTINGN I DATk I BY
SEWER OR DISPOSALSVSTEM 1.00 _
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1.00 CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR GRAINFIELD 2.00 STATION S DEPTH
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 2.003el
/ NHOLE REFERENCE
2 UPPER LOWER
TYPE OFq qN ECTION LENGTH FROM
OWNERS PERMIT $ I I oo <LD°R8i �. M.L.TO P.L. .3,5
AUTHORIZATION TOTAL FEE Ig o
1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER
SIGNED THIS_F+�.. .......DAY OE_')-YT/✓_.i..:f -19. 0q'I NEW HOUSE SEWER
ER OR ✓. GJ/ c /1 CONNECT ADDITIONAL
OWNJ
OWNERS AGEN .F' '7T/r' l // Al BUILDING OR WORK
C9J �9 �Y/) SEPTIC TANK,SEEP.PIT(S)
ADDRESS_.F:'1."_2_. _ 4 _4 -2. f�c....l..c!c.._. AND/OR GRAINFIELD
1 HEREBY ACKNOWLEDGE THAT i HAVE READ THIS APPLI. CESSPOOL D DRYWELL E]
CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER, REPAIR,SEWER OR
REGULATING PLUMBING AND SEWERS. SYSTEM
DISPOSAL SEWAGE DIS
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED DISCONNECT DIS PLUG AND
AND/OR LICENSED AS REQUIRED By LOS ANGELES COUNTY
AND STATE OF CALIFORNIA OR THAT 1 AM THE LEGAL OWN. ABANDON HOUSE SEWER
ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY: BACKFILL SEPTIC TANKS
SIGNATURE SEEP.PIT(S)0 CESSPOOLS ScAY-q ck /,2-,72: - Sy
OF PERMITTE _ AA ..: ��• j
76AG42D 6C3 1/53 v Ts_