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5&E-663 12.54 APPLICATION FOR PERMIT 1
5&E-6
DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL--
Department of County Engineer
County of Los Angeles BUILDING !
WM. J. FOX, COUNTY ENGINEER ADDRESS L
CASSATT D. GRIFFIN, SUPT OF BUILDING LOCALITY
99
FOR APPLICANT TO FILL IN NEAREST / 7 ` , 71�- ,r
CROSS ST. :-
LEGAL
DESCRIPTION _LOT NO. ��'� �
BLOCK TRACT ' r- `s—- MAIL
ADDRESS r
OF BLDG .'j" 7
-77
SIZE OF LOT /ON LOT CITY TEL. NO.
USE OF jr -
BUILDINGSI 16'a! ,�{ y ,_e%'' DISTRICT N0. I GROUP MAP
CONTRACTOR ,+�. .� � �- DK / G
ADDRESS CONNECTION DATA r T
CITY TEL. N0. STATION .J�u/ DEPTH O
.- [; SKATE o MANHOLE REFERENCE
REGISTRATION NO./ . F ' . - �� f ❑ COUNTY— >� UPPER t`pyA
TYPE OF CONNECTION LENGTH FROM `
NO. IDESCRIPTION OF WORK FEE Y? CURB -fte. M.L.TO P.L.
HOUSE SEWER CONNECTING TO c+
PUBLIC SEWER $ 3.50
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00 _
CONNECT ADDITIONAL BLDG, OR CO. IMP. NO. / �1.. 2 JOB. NO.
WORK TO HOUSE SEWER 1.00 _ _ �
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM 1.00 TRUNK PERMIT NO. ROAD PERMIT Np.
DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT
AND/OR DISPOSAL SYSTEM_ 1.00 PERMIT NO.
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 2.00 INDUSTRIAL
CESSPOOL- DRYWELL + WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2.00 I CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT $ 1 00
AUTHORIZATION TOTAL FEE ' ti ;,''7 REIMBURSEMENT FEE
MED CON-
TRACTORI HAVE TTOSCONNECTDATE OTHEAABODVEWDESCR BED EXISTING TRCTEITH THE HEREIN ADWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER ,/
SIGNED THIS DAY OF / tt / 19:-y NEW HOUSE SEWER /—�;, , °
OWNER OR - CONNECT ADDITIONAL
OWNERS AGENT �> - _BUILDING OR WORK
^�, s r SEPTIC TANK, SEEP, PIT($)
ADDRESS tZ�J F.<e ^f"�`._ ` AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑ —
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER, REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIAL ROPE Y. BACKFILL SEPTIC TANKS 11///"""��� „� ✓1_
SIGNATURE ! j
3 SEEP. PIT(S) ❑ CESSPOOLS4'.`;-
OF PERMITTEE
WILLIAM J. F, X,COUN ENGINEER VALIDATION
BY Q2 5 a 0 S APR 12 4 4.5 7 to
DEPUTY DEPUTY
BY BY
0 DEPUTY �ff/// DEPUTY