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6&E H6D89 12 54 APPLICATION OR PERMIT � 1
8 Q E
DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISOSAL
' Deportment of County Engineer
County of Los Angeles J:7m
WM J FOX, COUNTY ENGINEER D
-CASSATT D GRIFFIN, SUPT OF BUILDING
FOR APPLICANT TO FILL IN NEAREST
CROSS ST
LEGAL
DESCRIPTION LOT NO �f' OWNER
BLOCK TRACT 7 9� MAIL
ADDRESS
NO OF BLDGS �oj
SIZE OF LOT NOW ON LOT CIT TE NO �
USE OF i
BUILDINGS , DISTg NO I GROUP I MAP
BK PG
CONTRACTOR I
ADDRESS CONNECTION DATA /�n.��
CITY TEL NO (7, STATION DEPTH F
❑ STATE MAN EFERENCE FF''
REGISTRATION NOi' ® ❑ COUNTY PPER
_6�---� TYPE OF CONNECTI LENGTH FROM /
NO DESCRIPTION OF WORK FEE Y CURB P L M L TOP L
HOUSE SEWER CONNECTING TO C
PUBLIC SEWER Q 4 3 50 J
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 100
CONNECT ADDITIONAL BLDG OR CO IMP NO �r�D JOB NO
WORK TO HOUSE SEWER 1 00 I
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM 1 00 TRUNK PERMIT NO ROAD PERMIT NO
DISCONNECT AND ABANDON SEWCR 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 CHARGES
CONNECTION CHARGE FEE
OWNERS PERMIT $ 1 00
AUTHORIZATION I TOTAL FEE 3Q- REIMBURSEMENT FEE
TRACTORHAVE T TO CONNECTHIS DATE ONTRTHEA ABODVE DESCRIBED EXISTINGTHE HEREIN A DWELLING APPROVALS DATE INSPECTOR S SIGNATURE
TO THE PUBLIC SEWER
SIGNED THIS ZZ DAY OF 193 NEW HOUSE SEWER o� �' ru, �'„ ✓/'
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT ,{ -- BUILDING OR WORK
�-y� �. SEPTIC TANK, SEEP, PIT(S)
ADDRESS , �.,"�'
���� AND/OR DRAINrIELD
1 HERE 'CKNOWGE THAT 1 V
LEDE 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 P PERTY BACKFILL SEPTIC TANKS❑�,.,�r
O SEEP PIT(S) ❑ CESSPOOLS"d - 2.� �
SIGNATURE .47
OF PERMITTEE /
WILLIAM J. FOX. COUNTY ENGINEER VALIDATION
BY _.SCO I 5 3 7' JUL 12 4 4.5 0 �
DEPUTY DEPUTY
BY BY
-1® DEPUTY