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DFIPAR12CENT OF OOUNTY ENGINEER SEWER—SEWAGE DISPOSAL 1
DMSION OF BUELDING AND SAFETY PERMIT APPLICATION
ti COUNTY OF IAS ANOEI.E�
WILLIAM J. FOX, COUNTY ENGINEER BUILDING
ADDRESS . t5 �Q�
FOR APPLICANT T_Q FILL IN LOCALITY
BUILDING �7 i NEAREST
ADDRESS ? i ROSS ST.
LOCALITY DISTRIOT NO. SERIAL NO. PERMIT NO.t-
„��� � � j � � �
NEAREST s
CROSS ST. c
CE VED RaadY ter lupeirtJs■ DAT[ISSUED
OWNER �+ --.c96
MAIL USE ZONE OOCUPANOY BK NrRP��
ADDRESS r
r
OI TiLM0.
e/
OONTRAOTOB e6CO.IMP.M0.
ADDRESS JOS.NO.
CITY TELM TRUNK PERMIT NO.
E
REGISTRATION M0. COUNTY ROAD PERMIT NO.
LEGAL STATE ENCROACHMENT
DESOBIPTIOM L NO. PERMIT NO.
BLOCK TRACTL7 �r� INDUSTRIAL
WASTE APPROVAL
SIZE OF LOT NO.OF CLOCHARGES
NOW ON LOTT
USE OF
BUILDINGS L CONNECTION CHARGE fi
NO. DE:BCRIRTION OF WORK FE[
OUSE SEWER CORME IM 0 REIMBURSEMENT FE
PU8LIOSEWER ! L58 ✓� REOEIPTNO. DA BY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM I.M
CONNEff ADDITI BLDG.OR EXCOTION RECORDED
WORK TO HOUSE SEWER I M
ALTER OR REPAI STI MG M0' DATE BY
SEWER OR DISPOSAL SYSTEM I.M
DISOONNFOf AND AND OR DISPOSAL SYSTEMM a [e 1.02 CONNECTION DATA
SEPT I0 TANK.S PAQE PIT OR m
PITB ANDOR DRAINFIELD 2AO STATION DEPTH �—
CESSPO L.%RYWELL
SPEOIAL DONDIT70NS ONLY 2.M / MANHOLEREFERENCE
FERENCE
4:11 LOWER
Li E OF 00NNEOTION LENGTH FROM o
OWNERS PERMIT 1 &— P.L U.1-TO P.L. Q
AUTHORIZATION TOTAL FEE ✓D
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR' SIGNATURE DATE
OWELUNG TO THE PUBUO SEWER
SIGNED THIS• DAY OF 19_ NEW HOUBE SEWER
CONNECT ADDITIO
OWNER OR BBUILDING OR WORKAL
OWNERS AGENT
SEPTIC TAM SEEP.PIT(8)
ADDRESS AND/OR DRA NFIELD
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS ArPU- GESSP00L DRYWELL
CATION AND STATE THAT THE ABOVE 18 CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINAMO[S AND STATE LAWS ALTER,REPAIR.SEWER OR
REGULATING PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED
AND/OR LICE MBED AS REQUIRED BY LOS ANGELES COUNTY DISCONNECT PLUG AND
AND STATE OF CALIFORNIA OR THAT I AN THE LEGAL OWN. ABANDON HOUSE SEWER
ER OF THE ABOVE DIBED RESIDENTIAL PROPERTY. 13AOkFILL SEPTIC TANKS❑
81QNATURE � SEEP.PIT(p� OES8POOL8
OF PERMITT
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