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DEPARTMLNT OF COUNTY ENGINEER SEWER-SEWAGE DISPOSAL 1
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER hl ADO EISS 141012h , (n
FOR APPLICANT TO FILL INlf 1 LOCALITY ,
BUILDING ` NEAREST
ADDRESS t CROSS ST
LOCALITY DISTRICT NO A A SERIAL N PERMIT NO C
CNEAREST ROSS ST Q c3 �LO,3 �S
1 Ready for Inspection DATE ISSUED
R CEI ED BY
OWNER yrj� 9�a2`9L
MAILUSE ZONE OCCUPANCY B
ADDRESS
CITY TEL NO. � ; C L /��--
CONTRACTOR s4 CO IMP NO S
ADDRESS JOB NO
t
CITY 1-/ ±� TEL NO -T/'► TRUNK PERMIT NO
�/ COUNTY, : �6-
REGISTRATION NO ROAD PERMIT NO
LEGAL STATE ENCROACHMENT
DESCRIPTION LOT NO PERMIT NO
BLOCK TRACT S i INDUSTRIAL
WASTE APPROVAL
SIZE OF LOT W ON LOTS v j CHARGES
USE OF
-BUILDINGS f (ty . - I CONNECTION CHARGE EE
NO DESCRIPTION OF K FEE 117 ,I
REIMBURSEMENT FEE
HOUSE SEWER CONNECT0 v q'
PUBLICSEWER $ 380 St:, RECEIPT NO ATE I BY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1 00
CONNECT ADDITIONAL BLDG OR Tn EXXPTIO'l RECORDED
WORK TO,HOUSE SEWER 1 00 (J NO
ALTER OR REPAIR EXISTING I ATE I BY
SEWER OR DISPOSAL SYSTEM 1 00
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1 00 CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD - 200 STATION DEPTH
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 200 ^ MANHOLEUPPER REFERENCE
TYPE OF CONNECTION LENGTH FROM
`
.i4 CURB P'— M L TO P L
OWNERS PERMIT ; I �. 00 I
AUTHORIZATION I TOTAL FEE
1 HAVE_THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING( ° APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO THE P%5fIC SEWER
a NEW HOUSE SEWER ' ,pp
SIGNED THIS �*`�``DAY OF_ r — 19 m Gd-"j,� 7—c3U 5`y
OWNER ^OR r CONNECT ADDITIONAL
1 BUILDING OR WORK
OWNERS A E �j rleLl - �/� �` SEPTIC TANK,SEEP PIT(S)
ADDRESS ���al _ bid^ AND/OR DRAINFIELD
\ 1 HEREBY ACKNOWLEDGE THAT AVE READ THIS APPLI= CESSPOOL E] DRYWELL Ej
TI
CA
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 1 SEWAGE DISPOSAL SYSTEM
/ I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED3 AND
PLUG DISCONNECT
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTYI ABANDON HOPLUGAND
AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL.OWN a
ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY BACKFILL SEPTIC TANKS
SEEP PIT(S)E] CESSPOOLS❑o f /D-/,
SIGNATURE _ j 7&•'6' '�
OF PERMITTEE
76A642A 663 7/53