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DEPARTMENT OF COUNTY ENGINEER SEWER-SEWAGE DISPOSAL 1
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
o WILLIAM J. FOX, COUNTY ENGINEER I ADD BUILEISSs4'r 'Al r'16//�{�/f/
FOR APPLICANT TO FILL IN LOCALITY
BUILDING r/� CDISTRICTO � SERIAL NO Q�4Jd
NEAREST
LOCALITY PERMIT NQ
ADDRESS '�� Q��
�� ��� O
NEAREST T �^ A a �9� ��i S
CROSS ST I
RECEIVED BY Ready for Inspection DATE ISSUED
OWNER I 4el)C'Cy IzMAI L S S
ADDRESS �j® USE ZONE OCCUPANCY MAP
BK PG
CITY Zw 6,vTEL NO /
CONTRACTOR CO IMP NO xz
ADDRESS JOB NO
CITY/ ,'SEL NO
TRUNK PERMIT NO 1
%J �� TATE
REGISTRATION NO r� COUNTY ROAD PERMIT NO
,.
DESCRIPTION LOT NO �� 'y .Sd O�s/ ks D� STATE ENCROACHMENT --
PERMIT NO
BLOCK TRACT Yew Acle, ' INDUSTRIAL
WASTE APPROVAL
i NO OF SLOGS 1
SIZE OF LOT.'�'G�� HOW ON LOT \ CHARGES
USE OF ' /����/
BUILDINGS /J-�T' J CONNECTION CHARGE FEE
NO DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING-TO - REIMBURSEMENT FEE. _
PUBLICSEWER Q S -3 eI RECEIPT NO I ATE BY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 100
CONNECT ADDITIONAL BLDG OR _,--""EXCEPTION RECORDED
WORK TO HOUSE SEWER 1 00
ALTER OR REPAIR EXISTI G NO I DATE I BY�
SEWER OR DISPOSAL SYSTEM 1 00
DISCONNECT AND ABANDON SEWER _
AND/OR DISPOSAL SYSTEM 1 00 CONNECTION DATASEEPA "
NK
PTS ANDSEPTIC A/OR DRAINFGIELDIT OR 200 STATION to 7t-dl✓ _ DEPTH QA
CESSPOOLDRYWELL MANR PER / �HN/�O/� LOWER
SPECIAL CONDITIONS ONLY 200
TYPE OF CONNECTION LENGTH FROM
I
Y�CURB Fd R-L--__M.L-TO.0.'- �
OWNERS PERMIT $ I 1 00 _
AUTHORIZATION TOTAL FEE
CONTRACTOR TO CONNECT THE HAVE THIS DATE CONTRACfE
EE ABOVE DESCRIBED WITH THE HEREI
SCRIBEDI EXISTING ED APPROVALS INSPECTOR'S SIGNATURE _.DATE
DWELLING TO THE PUBLIC SEWERS `
SIGNED THIS /yy DAY OF/�G:._14' QC 1 NEW HOUSE SEWER
OWNER OR Vf:�/��r - I CONNECT ADDITIONAL
OWNERS AGEN _ BUILDING OR WORK
SEPTIC-TANK SEEP P
ADDRESS ,. �..1, - �fr� ��v�✓ _ AND/OR DRAINF ELD IT(8) r
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI- CESSPOOL DRYWELL 41
CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER REPAIR SEWER OR
REGULATING PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY DISCONNECT PLUG AND
AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN_ ABANDON HOUSE SEWER :
ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY BACKFILL SEPTIC TANKS Ej
SIGNATURE �/))/' /�� '�1 /, h SEEP PIT(S)E] CESSPOOLS
OF PERM
ITTEG!•�Pr �Z (`d °
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