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6APPLICATION FOR PERMIT
CE808
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BU ILOINc /y
JOHN A. LAMBIE, County Enginoo[ ADDREss -'I oBROAn
WILLIAM A. JENSEN, Supt of Building {—
LOCALITY � ,�'.G /JTtI
11
I NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL _ �j l
DESCRIPTION LOT NO. �v,/[(JRC� o �J 1,' OWNER I 4+A�/� A�r <�� T'[lilt
l—'rS-5 Q / _VV MAIL �'c1-`i--E-/.s1-" ��11[
BLOCK TRACT ADDRESS C
NO, OF FLOGS, [
SIZE OF LOT /_ I, '/ lAe� N LOT
E CITY TEL. NO.
VSOF VVV6AA"'AAA+"'TTT �•.VV/�v
BUILDINGSDISTRIC///T NO. OR MAP PROCESSED BY
CONTRACTOR /n f�//��C R L 1 /. �K P3 /
ADDRESS {/—"L][_(•,—•` J /v CONNECTION DATA
CITY TEL. NO. STATION DEPTH
STATE MANHOLE REFERENCE UPPER
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. r
PUBLIC SEWER ® $5.00 P.C.NO, a
SEPTIC TANK,SEEPAGE PIT OR CO. IMP, NO. JOB NO. O
PITS AND/OR GRAINFIELD ® 510.00 v
NO U SE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM Q 53.00 K
CONNECT ADDITIONAL' �}.{� AFFIDAVIT MMY[[ En5[NtNi RECORD.INSTfl.NO. DATE O
WORK TO HOUSE SEWER ® $3.p0 (/ V Y�
OVERFLOW SEEPAGE PIT,DRAINFIELD CWJ
EXTN.,CESSPOOL,DRYWELL.MANHOLE® 55.00 y
ALTER,REPAIR OR ABANOON HOUSE HWY.OR ST,WIDENING yI
SEWER OR DISPOSAL SYSTEM 53.00 STATE ENCROACHMENT Z
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL / (f
OWNER'SPERMIT �s �z 00 CHARGES
AUTHORIZATION 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'S SIGNATURE
SIGNED THIS MAY OF.
OWNER OR C 'NEW HOUSE SEWER -
OWNERS AGENT- � '
CONNECT A NgL
ADDRESS
BUILDING ORR WORK
SEPTIC TANK,SEEP.PIT(S) /F
HEREBY ACKNOWLEDGE THAT 1 READ THIS APPLICATION gry0/OR DRAIRAINFIELD
ANO STATE THAT THE ABOVE ICORRECREC T AND AGREE COMPLY
WITH ALL COUNTY ORDINANCES
S AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ ORTWELL ❑
1HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR ALTER.REPAIR.SEWER OR
LICEN 5ED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE O I.P.SAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF. AND INTEND TO DISCONNECT PLUG AND
RESIDE IN. THE ABOV E. DESC R I B ED RESIDENTIAL PROPERTY. ABANDON HOUSE SEWER
SIGNATUREL BACKFILL SEPTIC TANKS LlOF PERMITTEE ❑
SEEP.PIT IS
❑ CESSPOOLS
VALIDATION-� ROBERT( WOOD SUPERVISING MECHANICAL ENGINEER
CK. M.o, cgsH
_iiLo9 8 % 3RfIR25 1 0 0 5.00- v
CE40610'63• APPLICATION FOR PERMIT
I6A6gz0
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL.
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING n _ _ /
JOHN A. LAMBIE. County E.gi...' ADDRESS C/ Itl J y L�t�
WILLIAM A. JENSEN. Sup't of Building�j
OCALITY
NEAREST
F�4 /A(/(PeDYLICANT FI /�jJt RO05 ST. `
LEGAL 'r'�N(�"/Np� J / . OWNER
DESCRIPTION LOT
BLOCK TRACT �2 _ C4I•��^���� ADDRESS ^ /y�
NO. OF L.G5.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF
DI
BOIL OINGS DISTRICT NO, GROUP MAP PROCESSED BY
CONTRACTOR `"
ADDRESS Ct-G a CONNECTION DATA -^5
' STATION'7, Il' ` ,
CITY
DEPTH
,( fA
❑ MANHOLE REFERENCE `
REGISTRATION NO. ❑ COUNTY �- L" /�" LI LOWER
NO. DESCRIPTION WORK- FEE TYPE OF TION LENGTH FROM
HOUSE SEWER CONNECTING TO '' T. CURB J P.L. M.L.TO P.L. }
PUBLIC SEWER S.
P.C.NO. d
SEPTIC TANK.SEEPAGE PIT OR
PITS AND/OR DRAINPIE40 @ SIO.00 CO,IMP.NO. JOB NO. O
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT R/q'�
PRIVATE DISPOSAL SYSTEM @ $3.00 I /
CONNECT O ADDITIONAL
SEWERLDG.OR $3.00 `^ /`FFIOAVIT WAlvu us[KINT RECORD,INSTR,NO, GATE O
K TO
HOUSE
OVERFLOW SEEPAGE PIT.GRAINFIELD / '
EXTN..CESSPOOL.DRYWELL.MAN HO LE 0 $5.00 W
ALTER.REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING y
SEWER OR DISPOSAL SYSTEM ® S3.00 STATE ENCROACHMENT Z
PERMIT NO.
IND05TP IAL
WASTE APPROVAL
OWNERS PERMIT S z 00 CHARGES
AUTHORIZATION TOTAL FEE , CONNECTION CHARGE FEE
'I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMIED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBE° EXISTING DWELLING APPROVALS
TO THE PUBLIC SEWER, DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19_ � �p
OWNER OR [�//�rA a NEW HOUSE SEWER
OWNERS AGENT a c[�V a&E/�
l� CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS SEPTIC TANK.SEEP.PIT(S) 'F F
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION ANO/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY OP°INANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS, CESSPOOL ❑ DRYWELL ❑
HEREBY CERTIFY THAT 1 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 OF. AND INTEND TO °ISCONNECT PLUG AND
RESIDE IN, THE ABOV DESCRIBED RESIDENTIAL PROPERTY. ABANDON HOUSE SEWER
t
SIGNATURE
PERE BACKFILL SEPTIC TANKS ❑
OF PERMITTEE SEEP,PIT(5) ❑ CEBSPOOLA
VALIDATION-1 ROBERT A: WOOD
CK, M.D. ( �H SUPERVISING MECHANICAL ENGINEER