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DEPARTDfENT OF COUNTY ENGINEER SEWER—SEWAGE DISPOSAL
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES - ,a
WILLIAM J. FDX, COUNTY ENGINEER I BUILDING
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FOR APPLICANT TO FILL IN LOCALITY Tinfg/e. Civ4
BUILDING Q NEAREST / _��r
AUILDINr CROSS ST.F-Cl YzY K T
LOCALITY DISTRICT N0. SERIAL N0. ' rPER�r MIT NoO.
NEAREST I A ����� 14 S
CROSS ST.
— ' RECEIVED BY Ready for Ina Oaetlon DATE ISSUED
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ADDRESS
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CITU TEL.NO. b FPERMIT
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ADDRESS
CITY �' yy TEL.NO.' E
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REGISTRATION NO. ASS--J 2 ❑ COUNTYLEGAL — qG G
DESCRIPTIONLOT NO. J 7 fes/ G- ' ACHMENT
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BLOCK TRACT N/ � -�uY�/ INDUSTRIAL
WASTE APPROVAL
SIZE OF LOTh NO OF SLOGS. -'-+
�i NOW ON LOT L CHARGES
USE OF
BUILDINGS � CON NECTIDN.I`ARGE FEE
NO. DE C IPTION OF WORK FEE
HOUSE SEWER CONNECTING TO .y
REIMBURSEMENT FEE
PUBLICSEWER CN S 3.50 SD RECEIPT NO. ATE BY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLOC.OREXCEPTION RECORDED \
WORK TO HOUSE S EWER 1.00 \
SEWER OR OR DEISPOSAL SYSTEM 1.00 PAIR EXISTiNG1�1�
NO. DATE IBY
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1.00 CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR
"IS
AND/OR DRAINFIELD 2.00 STATION �J'j��o% •� DEPTH
CESSPOOL—ORYWELLon
SPECIAL CONDITIONS ONLY 2.00 /' MANHOLE REFERENCE
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TYPE—OFCURB ECT HP.L. __—LENGTHL.O
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OWNERS PERMIT f I 00
AUTHORIZATION TOTAL FEE ,l
1HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO THE PUBLIC SEWE •� ` 0�
SIGNED THIS/ .�.........DAY OF�... .. ---- 19.1. NEW HOUSE SEWER
OWNER OR .-}rn - CONNECT ADDITIONAL
OWNERS AGENT.�� .. ....(((.Y.1/..�..V ....�_� BUILDING OR WORK
qqSEPTIC TANK.SEEP.PITS)
ADDRESS_....Ly.�_y�.�.._-.- ..¢rtB�w_�. -.--- AND/OR DRAINFIELD
T �
I ON ANY STATEACKNOWLEDGE THAT I HAVE READ THIS APPLI- CESSPOOL❑ DRVWELL❑
CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO COMPLY WITH ALL COU ORDINANCES AND STATE LAWS ALTER, REPAIR,SEWER OR
REGULATING PLUMBING ANDD SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AMPROPERLY REGISTERED DISCONNECT PLUG AND
ST
AND/ LICENSED REQUIRED BY LOS ANGELES COUNTY '
AND STATE OF CALIFORNIAF B OR THAT I AM THE LEGAL OWN-
ABANDON HOUSE SEWER
ER OF THE ABOVE ESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTICTA
SIGNATURE ❑[n
/ / �I SEEP.PIT(S)❑ CESSPOOPOO LS f V
(Jj�/
OF PERMITTEE . __._ . ...._. ..... ___. .
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