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S&E 663 I2 54 APPLICATION FOR PERMIT
1 5&E 6
DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL
Deportment of County Engineer
County of Los Angeles BUILDING
WM J FOX, COUNTY ENGINEER
CASSATT D GRIFFIN, SUP T OF BUILDING LOCALITY 1✓--•.� ��' J l
FOR APPLICANT TO FILL IN NEAREST �f
CROSS ST !J L!
LEGAL v � _
DESCRIPTION LOT NO OWNER ,,,)
I
BLOCK TRACT i� D MAIL
NO OF BLDGS. Y �.,,C /i•,- �y,JJ �
SIZE OF LOT NOW ON LOTi SCI � TEL O
USE OF f /�
BUILDINGS DISTRICT NO GROUP MAP
J I I BK PG el
CONTRACTOR
ADDRESS I " - �,�,1 I CONNECTION DATA �V 7T-
CITY I> >1 / TEL / 11 �'� STATION C�f r DEPTH 7 a
f r
<. (STATE / pNHOLE REFERENCE
REGISTRATION NO [I COUNTY I y�� R UPPER R.
TYPE OF CONNE '1 LENGTH FROM
NO DESCRIPTION OF WORK FEE Y CURB P L M L TO P L
HOUSE SEWER CONNECTING TO
_PUBLIC SEWER Q $ 3 50 _
HOUSE SEWER CONNECTING TO
_ PRIVATE DISPOSAL SYSTEM 1 00
CONNECT ADDITIONAL BLDG OR
\YORK TO HOUSE SEWER 1 00 CO IMP NO JOB NO/
ALTER OR REPAIR EXISTING --tt--
SEWER OR DISPOSAL SYSTEM 1 00 TRUNK PERMIT NO ROAD PERMIT N
DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT
AND/OR DISPOSAL SYSTEM 1 00 PERMIT NO
SEPTIC TANK, SEEPAGE PIT OR
PITS AND/OR DRAI NFIELD 2 00 INDUSTRIAL
CESSPOOL- DRYWELL WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2 00 HA GES
CONNECTION CHARGE FE
OWNER'S PERMIT 3 1 00
AUTHORIZATION I TOTAL FEE (-0 REIMBURSEMENT FEE
TRACTORHAVE TO CON ECTHIS DATE ONTRTHEA ABOVE DESCR BEDCTED WITH THE HEREXISTINGA DWELLING APPROVALS DATE INSPECTOR S SIGNATURE
TO THE PUBLIC W _
SIGNED THISDAY OF s 19�6 EW HOUSE SEWER _9_r <� � d
OWNER OCONNECT ADDITIONAL
OWNERS NT O / BUILDING OR WORK
ADDRESS mI / (,.�1 SEPTIC TANK, SEEP, PITS) (,
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I!AVE READ THIS APPLICATION CESSPOOL[__1DRYWELL[3AND STATE THAT THE ABOVE IS C RECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER, REPAIR,SEWER OR _
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
I hEREBY CERTIFY THAT 1 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 A �,j��p
DESCRIBED RES1 NTIAL P OP Y BACKFILL SEPTIC TANKS[I
SEEP
� J} ...y t"
SEEP PIT(S) ❑ CESSPOOLS
SIGNATURE
OF PERMITT
WILLIAM J. FOX. COUNTY ENGINEER VALWATION
BY ACO 7 6B9 5,'--, SEP 8 4 5.5 0 m
DEPUTY DEPUTY
BY BY U
® DEPUTY DEPUTY