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CEHOB B•HB APPLICATION FOR PERMIT
7
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL 1
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING J
ADDRESS O
TORN A. $•AMBLE, Count, Sup of Builds
CASSAT7 D. GBR°F'Ri, Supft 07 Building LOCALITY �-
NEAREST e
FOR APPL//iJJCnnRNT TO FILL IN cnoss sr. a
DESCRIPTION r 1. 0.'.11 f OWNER
BLOCK TRACT '' / MAIL
J DAA T�f(N ,c P ADDRESS
NO.OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF
BUILDINGS e DISTRICT NO. GROUP MAP P ESSED
PG
CONTRACTOR OZ ,PL✓P/ O�✓I/ .,,� I �f�
ADDRESS �/ ,[ILOC_ I CONNECTION DATA
CITY •�AA/T TEL.N0.G- "`2 TIO DEPTH /
STATE MANHOLE REFERENCE PP
REGISTRATION N0. COUNTY
No. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO '7
PURL
IC SEWER @ $3.00 O`7J TYPE OF CONNECTION LENGTH FROMSEPTIC TANK.SEEPAGE /.
PTS AND/OR DRAINFIELD OR @ $3.00 Y. CURB P.L. L.TO P.L.
OVERFLOW SEEPAGE PIT, DRAINFIELD
EXTN..CESSPOOL. DRYWELL @ $2.00
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM @ $1.00 CO.IMP. NO JOB NO.
WORK CONNECT ADDITIONUSE A L LDG.OR @ 41 00 TRUNK PERMIT N0. ROAD PERMIT NO O
ALTER, REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
SEWER OR DISPOSAL SYSTEM @ 81.00 PERMIT No.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT 3 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
I NAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR To CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER. O
SIGNED THIS DAY OF 19_ NEW HOUSE SEWER •-0-2'
AGENT 61
lV�fJT:21 IX1�
OWNER N// CONNECT ADDITIONAL
-� BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP. PIT(S)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL ❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. ALTER,REPAIR,SEWER OR
SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY ANGELES COUNT AND STATE OF ABANDONCT PLUGA D
CALIFORNIA OR THAT 1 A THE LEGAL WNE OF THE ABOVE HOUSE
DESCRIBED RESIDENTIAL OPERTY. BACKFILL SEPTIC TANKS ❑
SIGNATURE n $ P. PIT(S) ❑ CESSPOOL ❑
OF PERMITTE l
®r LIDATION ROBERT A. WOOD
M.o. CASH .SUPERVISING MECHANICAL ENGINEER
1 10 6 7 4 72 FEET 1 9 T 0 A 5.0.0 ="
ESO
GS0-ss APPLICATION FOR PERMIT
seoe COUNTY OF LOS ANGELES
SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING t ,e
ADDRESS (9 17
CASSATT D. GRI IFIN SupOHN A. LAMBIE. t of Buddiuy
LDGALI //17
NEAREST
FOR APPLICANT TO FILL IN CROSS ST. �P
LEGAL /J T
DESCRIPTION LOT N pppf"""/( / , A .0 ��y..fff OWNER Y V
BLOCK TRACT eoVj s /O� Jy� 1Cfe1 ADDRESS
MAIL
/" NO.OF SLOGS.
SIZE OF.LOT NOW ON LOT CITY TEL. N0.
USE OF
BUILDINGS DISTRICT N0. GROUP MAP PR CE E
BK PG ��
CONTRACTOR .AIS 1 r /f(iL-
ADDRESS/ -/7 ,IAS PC/N�/l cc" CONNECTION-DATA
CITY (/(l�Jy r`p TEL. �'�/�`j /Y�'� ION DEPTH
REGISTRATION NO. /S/ ` 7 - �y 2 COUNTY M NHOLE REFERENCE '� PP
No. DESCRIPTION OF WORK FEE W-9FT r h f
HOUSE SEWER CONNECTING TO _
PUBLIC SEWER @ $3.00 TYPE OF CONNECTION LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR Y. CURB P.L. M.L. P.L.
PITS AND/OR DRAINFIELD @ S3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN,. CESSPOOL. DRYWELL @ $2.00
HOUSE SEWER CONNECTING TOP' O.
PRIVATE DISPOSAL SYSTEM @ $1.00 CO.IMP. N0. JOB NO.
CONNECT ADDITIONAL BLDG.OR
WORK TO HOUSE SEWER @ $1.00 TRUNK PERMIT N0. ROAD PERMIT N0.
ALTER,REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
SEWER OR DISPOSAL SYSTEM @ I.00 PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS I PERMIT $ CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE REIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON.
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
To THE PUBLIC SEWER.
SIGNED THIS DAY OF19— NEW HOUSE SEWER
OWNER CONNECT ADDITIONAL
WORK A
OWNERS AGENT �� BUILDING OR WORK
ADORES R
SEPTIC TANK,SEEP. PIT(S)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ ORYW ELL ❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. ALTER,REPAIR,SEWER OR
SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/Oft DISCONNECT PLUG AND
LICENSED AS REQUIRED A LOS ANGELES OW NO STATE OF ABANDON HOUSE SEWER
CALIFORNIA ES THAT I AM HE LEGAOW OF THE ABOVE
DESCRIBED RESIDENTIAL , ERTY. f SACKFIILL(SSEPTIC TANKS 0❑S
SIGNATURE
OF PER E _ L
®� TI
ALIDAON l� ROBERT A. WOAD
41,
CK. M.0. CASH SUPERVISING MECHANICAL ENGINEER
t,D6748S FEB 1G11. A 25.00