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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
FOR APPLICANT TO FILL IN LOCALITY
BUILDING NEAREST /
ADDRESS n 4 :tom,s� S CROSS ST.
LOCALITY I - DISTRICT NO. SERIAL NO. PERMIT NO.
NEAREST A lJ �� J
CROSS ST. ; s-•.
RECEIVED BY Ready for Inspection DATE ISSUED
OWNER A ST. -� .. tMAIL f IA
ADDRESS ^ 1'^ �^� i)rt .�ytQ '•+/ OUSE ZONE OCCUPANCY MAP
BK PG
CITY 'r7_t- I ^,c .,- TEL.NO.
I
CONTRACTOR Y d,,{ tom —r CHARGES REIMBURSEMENT FEE
ADDRESS h ° L=7:G REQUIRED
p� NOT REQUIRED
CITY Afk/ (/ `TELAO. JOB.N0.
CONNECTION CHARGE FEE
REGISTRATION NO. S,CD�{1kiEV �r >, CO.IMP.NO.
LEGAL r y L RECEIPT NO. DATE I BY
DESCRIPTION LOT N0.
BLOCK TRACT
� `' !'� }- WAIVER FOR RECORDING
SIZE OF LOT NO.OF BLDGS.
USE OF NOW ON LOT RECEIPT N0. I DATE I BY
BUILDINGS TRUNK PERMIT N0.
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO ROAD PERMIT NO.
PUBLIC SEWER $ 3.50
HOUSE SEWER CONNECTING TO STATE ENCROACHMENT
L-PRIVATE DISPOSALSYSTEM 1.00 / PERMIT NO.
CONNECT ADDITIONAL BLDG.OR INDUSTRIAL
WORK TO 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 DEPTH
EPTIC TANK,SEEPAGE PIT OR
1_101ITS AND/OR DRAINFIELD 2.00 MANHOLE REFERENCE
CESSPOOL—DRYWELL UPPER LOWER
SPECIAL CONDITIONS ONLY 2.00 TYPE OF CONNECTION LENGTH FROM
Y. CURB P.L. M.L.TO P.L.
OWNERS PERMIT 00
AUTHORIZATION TOTAL FEE4-111,
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
SIGNED THIS--------- -- ----DAY OF------------------------............... 19........ NEW HOUSE SEWER i ri C� 3
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT.................................................................................. BUILDING OR WORK
EPTIC TANKSEEP.
ADDRESS- AND/OR DRAINFIELD PIT(S) !� Y
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI- CESSPOOL 0 DRYWELL E]CATICN 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
1 HEREBY CERTIFY THAT IAM PROPERLY REGISTERED DISCONNECT PLUG AND
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOUSE SEWER
AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN-
ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS
SEEP.PIT(S)E] CESSPOOLS
SIGNATURE
OF PERMITTEE .`�!�'` -- ------------- --------- /i?
76A6421) 663 12/52