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DEPARTMENT OF COUNTY ENGINEER SEWER-SEWAGE DISPOSAL 1
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER BUILDING /' =
CASSATT D. GRIFFIN, SUPT OF BUILDING ADDRESS '� /j ,,' �J,�,�r d (%l✓,' 1
FOR APPLICANT TO FILL IN LOCALITY
BUILDING
�I4��2� r NEAREST r`
ADORE SS �_//' t/LG �!'ZC� CROSS ST.
LOCALITY 6(/�J o_ DISTRICT NO. SERIAL NO. PERMIT NO.
NEAREST J A / S
CROSS ST.
RECEIVED BY Ready for Inspection DATE ISSUED
OWNER
MAIL / Q r
ADDRESS ] USE ZONE OCCUPANCY MAP
I BK PG
CITY a L, tL_ TELAO. 7a 60/ -7
CONTRACTOR a, CHARGES REIMBURSEMENT FEE
ADDRESS 5922 NO- ENCINITA AVE REQUIRED
TEMPLE CITY AT-6-n s N�REQUIRED--
CITY TEL.NO. 4CONNECTION CHARGE FEE
STATE
REGISTRATION NO. OAtlifTT CO. IMP.NO.
LEGALRECEIPT NO. I DATE I BY
DESCRIPTION LOT NO. (7 7 I
BLOCK TRACT Cp WAIVER FOR RECORDING
SIZE OF LOTNO.OF BLOCS.
USE OF
O-(41 'NOW ON LOT Lr7[Qr RECEIPT NO. I DATE BY
BUILDINGS •> �,wteL �GIILQ —
TRUNK PERMIT NO.
N0. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO - ROAD PERMIT N0. !
PUBLICSEWER @ $ 3.50 ---
HOUSE SEWER CONNECTING TO STATE ENCROACHMENT
PRIVATE DISPOSAL,SYSTEM 1.00 PERMIT NO.
CONNECT ADDITIONAL BLDG.OR INDUSTRIAL
-WORKTO HOUSE SEWER 1.00 WASTE APPROVAL
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM 1.00 CONNECTION DATA
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1.00 STATION /D �. �/ _ DEPTH
SEPTIC TANK,SEEPAGE PIT OR ---,
PITS AND/OR DRAINFIELD 2.00 MANHOLE REFERENCE "I
CESSPOOL—DRYWELL I UFRER .� L� ^ LOWER
SPECIAL CONDITIONS ONLY 2.00 TYPE OF CONNECTION LENGTH FROM
-Y.. CURB 44&w M.L.TO P.L. '
OWNERS PERMIT $ 1 1 00
AUTHORIZATION I TOTAL FEE I>
I.
I 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 r
SIGNED THIS----090.-....DAY OF---- -------------------_ 19.J.z NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGEN ----F- .. ..
__ BUILDING OR WORK
SEPTIC TANK,SEEP.PIT S)
ADDRESS-------- Q_S. ?.fS ..d'.. AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI- CESSPOOL g DRYWELL
CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER,REPAIR SEWER
REGULATING PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I
HEREBY CERTIFY THAT I AM PROPERLY R ISTERED DISCONNECT PLUG AND
AND/OR LICENSED AS REQUIRED BY LOS AN S COUNTY ABANDON HOUSE SEWER
AND STATE OF CALIFOR�I OR THAT AM LEGAL 0 N-
ER OF THE ABOVE DFSC BED REST N L ROPERTY.� BACKFILL SEPTIC TANKS
SEEP.PIT(S)E] CESSPOOLS 0
El
SIGNATURE
OF PERMITTEE---� -- -� --••-- --^`.....:.. .:... .
i6A6421) 663 12/52