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S&E 663 12 54 APPLICATION FOR PERMIT 9
S&E 61
DIVISION OF BUMDING AND SAFETY SEWER-SEWAGE DISPOSAL
Department of County Engineer
1
County Of L08 Angeles BUILDING
WM J FOX. COUNTY ENGINEER ADDRESS i I
CASSATT D GRIFFIN. Sup'T OF BUILDING LOCALITY
FOR APPLICANT—TO-FILL IN NEAREST
CROSS ST sL-
LEGAL \ i
DESCRIPTION LOT NO OWNER
BLOCK TRACT MAIL °
ADDRESS 9 1�''l
NO OF BLDGS. _
SIZE OF LOT NOW ON LOT r IT .- y TE
USE OF �' MEM
BUILDINGS - .i - ii.�E r DISTRICT NO GROUP MAP
/ I .-r- I SK G
CONTRACTOR
ADDRES � r d CONNECTION DATA
Clf_Y i v TEL NO J STATION 'f' DEPTH
jjSTATE >j d-'MANHOLEUPPER REFERENCE
El
REGISTRATION NO d ❑ COUNTY if _
v YPE OF CONNECTION LENGTH FROM
NO DESCRIPTION OF WORK FEE Y CURB M L TO P L
HOUSE SEWER CONNECTING TO
PUBLIC SEWER Q $ 3 50
HOUSE SEWER CONNECTING TO
_ PRIVATE DISPOSAL SYSTEM 100CONNECT
O WORK TO HOUSE ADDITIONAL
SEWER BLDG OR 100 �u L� r l
CO IMP NO JOB NO
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM 1 00 TRUNK PERMIT NO ROAD PERMIT NO
DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT
pND/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 CHARGE
CONNECTION CHARGE FEE
OWNERS PERMIT g 1 00
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
TPACTORHAVE TTOS CONNECTDATE ONTRTHEA ABODVE WITH DESCTHR BE ,EX ESTINGAMED DWELLIING APPROVALS DATE INSPECTOR S SIGNATURE
TO THE PUBLIC SEWER
SIGNED THIS Y 9�Zc� W HOUSE SEWER TC090QV,_
OWNER OR CONNECT ADDITIONAL
OWNERS ENT BUILDING OR WORK
! ASEPTIC TANK, SEEP, PIT(S)
ADDRES �•� �' f, A*'"" AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT IAH VE READ THIS APPLICATION CESSPOOL[:I DRYWELL[jAND STATE THAT THE ABOVE IS COR�2ECT AND AGREE TO COMPLY _
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER, REPAIR,SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
1HEREBY 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 HE ABOVE
DESCRIBED RESIDENT15L P PERTY BACKFILL SEPTIC TANKS❑
Jr� SEEP P(T(S ❑ CESSPOOLS G7 p �
SIGNATURE /
OF PERMITTE Z�2 -
WILLIAM J FOX. COUNTY ENGINEER VALIDATION
BY �'IU 5 `Y 4 SEP g d 5.50
DEPUTY DEPUTY
BY BY !//I
` ® DEPUTY DEPUTY