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S&EGAPPLICATION FOR PERMIT
6DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Deportment of County Engineer
County of Los Angeles
WM.J. FOX, COUNTY ENGINEER AUDR ESS
CASSATT D. GRIFFIN. S.r'T OR BUILDING LOCALITY ".lY�aa u,�,
FOR APPLICANT TO FILL IN NEAREST
CROSS ST.
LEGA
L I
DESCRIPTION LOT NO. OWNER R �y
BLOCK TRACT / MAIL
ADDRESS
NO. OF SLOGS.SITE OF LOT J JkPW ON L T _ CITY TEL. N0.
USE OF
BUILDINGS .C.4 ^ Y —•�•'— DISTRICT NO. GROUP MAP
_ BK PG
CONTRACTOR ? 'ti �� 1
ADDRESS -. I CONNECTION DATA
CITY TEL NO. ��3 STATION STATE23 9/: / DEPTH j
REGISTRATION NO. ❑ COUNTY Jr 1 a% /W "p UPPER AAOLE REFERENCE
TYPE OF CONN 10 LENGTH FROM
NO. DESCRIPTION OF WORK FEE Y. CURB �r L.l M.L.TO P.L.
/ HOUSE SEWER CONNECTING TO
_ PUBLIC SEWER @ S 3.50
HOUSE SEWER CONNECTING TO
_ PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG, OR CO. IMP. NO. / JOB. NO.
--WORK TO HOUSE SEWER 1.00
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM 1.00 TRUNK PERMIT NO. ROAD PERMIT NO.
DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT
AND/OR DISPOSAL SYSTEM 1.00 PERMIT NO.
SEPTIC TANK, SEEPAGE PIT OR
PITS AND/OR GRAINFIELD 2.00 INDUSTRIAL
CESSPOOL-DRYWELL WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2.00 CHARGES
PERMIT CONNECTION CH9G FEE
OWNER'S a
AUTHORIZATION TOTAL. FEEREIMBURSEMENT FEE
I HAVE J� 57��o OLD GfSPL
CON-
TRACTORTTOS CONNECT THECTED ABOVEWITH THE DESCRBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
THE PUBLIC SEWLH
SI _
SIGNED THIS 1L DAY 19� NEW HOUSE SEWER � f(01'i
OWNER OR L'L' CONNECT ADDITIONAL
OWNERS AGE BUILDING OR WORK
ADDRESS SEPTIC TANK, SEEP, PIT(S)
AND/OR DRAINFIELD
I HEREB ACKNOWLEDGE THAT I READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER. REPAIR,SEWER OR
PLUMBING AND SEWERS. SELVAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AMOR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEW
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS❑
SEEP. PIT(S) ❑ CESSPOOLS❑
SIGNATURE
OF.PERMITTEE
WILLIAM J. FOX, COUNTY EN I ER VALIDATION
By ..—..::."V.�O5 5 1 �. JJL 1'2 4 4.5 0 in
BY
DEPUTY _ \/ yam/ DEPUTY
BY BY
0 DEPUTY DEPUTY