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76A 642D APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SKWER-SEWAGE PISPOgAL
DEPARTMHNT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN'A. LAMSIE, COUNTY ENGINEER ADORESS
COLEMAN W. JENKINS. SUPT. OF BU1LDtNG \
LOCALm
NEAREST
FOR APPLICANT TO FELL IN °R°" ST
LEGAL u
DESCRIPTION LOT NO. OWNER
MAIL
BLOCK TRACT ADOR[SS
OF ■,DO1.
SIZE OF LOT ON LOT CITY TQ. NO.
U/[ OF DIST711CT NO GROUP MAP PROCESSED Y
■U ILDING/ p B `
CONTRACTOR , `� r �3 rJU'Z•/fj!
ADDRESS r CONMCnON DATA /+
CITY TEL No. Ab 7J�4fkZ STATION 91
6ETT-t
fTA IC MANHOLE REFERENCE SCJ
LICENSE NO, CLAM
No. DESCRIPTION OF WORK FEE TYPE of CT[ON LENGTH FROM
HOUPUBLIC S[WERE SEWER CONN[CT1N0 TO . e/.00 40 Y P.L. M.L.TO F.L. f O'
/[DTIC TAN O[PIT / Fon NO.
Pl AND/OR DRAINFI[LD � •I0.00
Co.IMP.NO. JOS NO.
il
H OUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD FSRMIT NO.
PRIVATE DISPOSAL SYSTEM /1.00
CONNECT ADDITIONAL 15L.Da.OR AFFIDAVIT I SAmm [As"a f RECORD.INSTR.NO. DATE
WORK TO HOUSE SEWER $/.00
OVERFLOW■EBPAGE PIT.DRAINFIEID O
U[TN..CESSPOOL.DRYWELLMANHOLE 6 5e.00 F—
ALTIZIR.R AIR A D HOUSE HWY.OR ST.WIDENING UW
■[W[R OR DISPOSAL SYWMM P3.00 STATE QiCROACHoixper CL
PERMIT NO.
INDUSTRIAL
WAST[APPROVAL
CHARD[/
OWNERS PE 133 6 I OD
CON H
AUTHORIZATION TOTAL FU 400 [CTION CHARD[PEE
1 HAVE AT THIS DA TZ A LORT'RACT WfTH TR[ HEREIN NAMED CON- R[IMBU RI[M[HT FEE
TRACTOR TO_CONN[CT THE ABOVE D[SCRI S[D a DWELLING
TO THE PUSLIC APPROVAM rE IHIX� IVJIWLATURR
SIGNED THIS I
OWNER OR NEW HOUSE B4 WD1
OW N[RS AGE rrr
CONNECT ADDITIONAL
A DO RISS BUILDING OR WORK
I HEREBY ACKN OW L[DG[ THAT P
AVL READ THIS APLIGTION •LPTIC TANK.SEEP,PIT(S)
AND STATE THAT THE ABOVE 16 ORRECT AND AGREE TO COMPLY AHD/OR DRAINFIELD
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND S[WI!FM. CESSPOOL ❑ DRYWEL; ❑
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGIST[R[U AHD/OR ALTER.REPAIR.SEWER OR
LICEN/[D AS 14QUIRID BY LOf Li/ COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
GLI FORNIA OR THAT I AM THE GA OW OF, AND INTEND TO DISCONNECT PLUG AND
R[f ID[ IN. TH[ A D R IAL P11OP[RTY. ABANDON HOUSE■[WEA
•10F PER M}TTE[ ECKFILL/ IC TANKS ❑
SEEP.PTURE
IT{/ CESSPOOLS `
VALIDATION JACK R. ALLEN
M.o. GSH
SUPERVISING MECHAWCAL ENGINEER
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