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DIVISION OF BUILDING AND .SAFETY SEWER-SEWAGE D O SPOSA L
Department of County Engineer
County of Los Angeles LNEAREStTr
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WM. J. FOX, COUNTY ENGINEER
CASSATT D. GRIFFIN. SUPT OF BUILDING �••2�' Z
FOR APPLICANT TO FILL IN LEGALDESCRIPTION. LOT NO. OWNER
BLOCK TRACT + ./ MAIL
l
Ebr-�—�E ADDRESS `y�
N6. OF BLDGS. 'v C Al,
`" TE
SIZE OF LOT - NOW ON LOT Y/�,�_4.' 1 4 ' 2.
USE OF
BUILDINGS //iar ks lJ`-'`"� `rP
C .DISTRI NO: I - GROUP MAP
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CONTRACTOR / r „� �•�, r}. ✓ '
ADDRESS Fl ,. _" �.✓!_ �. ; �f CONNECTION DATA
C-tTY _ - TEL. O �� STATION DEPTH .� �
C G� G . /-
®>5•PATEr f �s•MAFIHOLE REFERENCE
REGISTRATION NO. ` i ❑ COUNTY / Gt. .�y_s UPPER_
"-'y - TYPE OF CONNE TIONe-7-. LENGTH FROM
No. DESCRIPTION OF WORK FEE - Y. CURB (-P.yJ M.L.TO P.L.
HOUSE SEWER CONNECTING TO
PUBLIC SEWER tt $ 3,:50
,HOUSE SEWER CONNECTING TO !J
_ PRIVATE DISPOSAL SYSTEM 1.00_
CONNECT ADDITIONAL BLDG. OR CO. IMP. NO. J08."N O.
WORK TO HOUSE SEWER 1.00
,ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM 1.00 TRUNK PERMIT NO. - ROAD PERMIT NO.
ANDDISCONNECTDISPOSAL
ABANDON SEWER STATE ENCROACHMENT O
AND/OR DISPOSAL SYSTEM " 1.00 PERMIT NO.
SEPTIC TANK, SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 2.00 INDUSTRIAL - r/
CESSPOOL DRYW ELL WASTE APPROVAL .✓y
SPECIAL CONDITIONS ONLY 2.00 - yCHA'R EG S
CONNECTION CHARGEFEE
OWNERS PERMIT $ 1 00 -
AUTHORIZATION TOTAL FEE -� REIMBURSEMENT FEE
CJUCA'�din
CON-
TRAI HAVE-CTOR TO CCONNECT DATE O THE ABOVE WDESCR DESITH THE CRIBED EXISTING DWELLING APPROVALS DATE INSPECTORS SIGNATURE
TO-THE'PUBLIC SE ER` NEW HOUSE SEINER
THIS DAY Op 19 -;I-
SIGNED
OWNER OR CONNECT ADDITIONAL
OWNERS A�ENT. !" i? BUILDING OR WORK
SEPTIC TANK;SEEP,PIT(S)
ADDRESS 4 nl. , r" '�� AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HANE EAD THIS APPLICATION CESSPOOL❑ DRYWELL[3 -
AND STATE THAT THE ABOVE IS CORR'EGT AND AGREE TO COMPLY -
WITH ALL COUNTY ORDINANCES AN�/STATE LAWS REGULATING ALTER, REPAIR, SEWER OR -
PLUMBING AND SEWERS. - SEWAGE DISPOSAL SYSTEM
-
IHEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR -
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND ..�
CALIFORNIA OR THAT AM THE LEGAL OWNER OF HE ABOVE ABANDON HOUSE SEWER- t
DESCRIBED RESIDENT! L -PERTY. BACKFILL'SEPTIC TANKS❑'
f SEEP. PITS) ❑_ CESSPOOLS / `� '
SIGNATURE
OF PERMI EE v
WILLIAM J. FOX, COUNTY ENGINEER VALIDATION
BY ..Al o 7Y3 9 E.s SEP 1 4.50 �.
DEPUTY :� _ .,_,DEPUTY
BY BY
- DEPUTY DEPUTY - -