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DEPAICTIMENT OF COUNTY ENGINEER SEWER—SEWAGE DISPOSAL
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
i.. WILLIAM J. -FOX. COUNTY ENGINEER I BUILDING
ADDRESS
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FOR APPLICANT TO FILL IN LOCALITY 7e/;I7'0BUILDINGNEAREST
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ADDRESS S~�-.LL ,IJ�G•'l+q��i--• CROSS ST. QQ`
LOCALITY DISTRICT NO. SERIAL NO. PERMIT NO.
NEAREST ? �J A `•g 4',O �� �U(� LF. S
CROSS ST.
OWNER
RECEIVED BY Ready for Inspection DATEISSUED
/ e ��. Pit//MAIL
ADDRESS S' G - % USEZONE OnCCUPANCY BK MAP PG
CITY TEL.NO. Y'C_Y/✓
CONTRACTOR - (�. +/Ls+-I��.
�-w � CO.IMP.N0. � J
ADDRESS-j JOB N0.
CITY � - /' TEL.NO. (k YD 3❑ YJ TRUMKPERMIT NO.
❑ COUNTY, ./ /. Cs•./ /
REGISTRATION NO. (� yr ROAD PERMIT N0. Y
DESCRLEGIPTION LOT NO.,3 I- 7 'u•�7 ��, J�'(f Fr STATE ENCROACHMENT
) PE RMIT'NO. ��^
BLOCK TRACT / �o�(J �55�1•1c�3�y INDUSTRIAL
/ WASTE APPROVAL
SIZE OF LOT b-6 )( / 2(e NOW ON LOTS CHARGES
NO.OF SLOG
USE OF n _
BUILDINGS L�6Lt1. CONNECTION CHARGE FEE
ND. DESCRIPTIO//N OF IVORK FEE_ `
HOUSE SEWER CONNECTING TO REIMBURSEMENT FEE_
PUBLICSEWER @ $ 3.50 RECEIPT NO. 'DATE BY
HOUSES DISPOSWER AL
SYSTEECTINGM
TO
PRIVATE DISPOSAL SYSTEM 1.00 �I
CONNECT ADDITIONAL BLDG.OR / EXCEPTION RECORDED `
WORK TO HOUSE SEWE R - 1.00 �(�
ALTER OR REPAIR EXISTING NO` I DATE I BY �.
SEWER OR DISPOSAL SYSTEM 1100
DISCONNECT AND ABANDON SEWER -
AND/OR DISPOSAL SYSTEM coo CONNECTION DATA
SEPTIC TANK;SEEPAGE PIT OR �I /
PITS AND/OR DRAINFIELD 2.00 ^ STATION % / DEPTH
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 2.00 / 2"� �/J ANHO LE ERREFERENCE CO_WER-
TYPE.OF CONNECTION LENGTH FROM
OWNERS PERMIT $ 1 00 Y. ML P.L. --M.L.TO P.L.
AUTHORIZATION I TOTAL FEE
1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING'
DWELLING TO THEAPPROVALS INSPECTOR'S SIGNATURE DATE
3�PPUBLIC SEWE
SIGNED THIS....-....1....-..DAY
OE_. - .... ----------- 196-- NEW HOUSE SEWER
OWNER OR ENT � _- ._^r -----' BUIILDING,ORRWORKAL C _l(✓.�G.rCJIT ���7��1 J
'OWNERS AG
ADDRESS:./ "fjL.. . ...,J:: .i .._,; •L.: tily. ,P�iid AND/OR GRAINFIELD
cPIT(S)
I HEREBY'ACKNOWLEDGE THAT I HAVE READ THIS APPLI- CESSPOOL Q DRYWELL
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
HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED .DISCONNECT PLUG AND
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY'
AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN. ABANDON HOUSE SEWER
ER OF THE ABOVE DESCRIBED E$_IDENTIAL PROPERT BACKFILL.SEPTIC TANKS El „ qqq / �/ �j / ry• �{
SIGNATURE
yy�� � SEEP.PIT(S)� CESSPOOLS
OF PERMITTEE/ a ...._{_/._.............._....._ .. _------_.—
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