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S&E 663 I2 54 ■APPLICATION OR PERMIT' 1
6&E 6
DIVISION OF BUR DING AND SAFETY SEWER—SEWAGE DISPOSAL
Deportment of County Engineer
County of Los Angeles BUILDIN
WM J FOX, COUNTY ENGINEER ADDRESS
i
CASSATT D GRIFFIN, Sup'T OF BUILDING LOCALITY
FOR APPLICANT TO FILL IN NEAREST I
CROSS ST LEGALOWNER DESCRIPTION LOT NOBLOCK TRACT "Z MAILADDRESSNO OF BLDGS. ,� �
SIZE OF LOT NOW ON LOT CITYC TIL
USE OF ��A /{.� �j _
BUILDINGS ,�I. Y '�*--'4 I/" DISTRICT NO GROUP MAP
�'
CONTRACTOR f� BK PG
^;J
ADDRE S !' ,� �'-z,,r ,l'..t.• "�• c CONNECTION DATA
CITY �/ R'EL NO ll STATION 0 G DEPTH
�SfATE / hjA NHOLE REFERENCE
�REGISTRATION NO , g q ❑ COUNTY / Z 6`./iUPPER Rr
TYPE OF CONNE LENGTH FROM
NO DESCRIPTION OF WORK FEE Y CURB P L M L TO P L ,
HOUSE SEWER CONNECTING TO
PUBLIC SEWER Q $ 356 � lJ
HOUSE SEWER CONNECTING TO
_ PRIVATE DISPOSAL SYSTEM 1 00 /
CONNECT ADDITIONAL BLDG OR CO IMP NO / 67(3 / JOB NO
WORK TO HOUSE SEWER 1 00
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM 1 00 TRUNK PERMIT NO ROAD PERMIT NO
DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT
AND/OR DISPOSAL SYSTEM 1 00 PERMIT NO
SEPTIC TANK, SEEPAGE PIT OR
P,TS AND/OR DRAINFIELD 2 00 INDUSTRIAL
CESSPOOL- DRYWELL WASTE APPROVAL
SPECIAL CONDITIONS ONLY 200 CHARG S
CONNECTION CHARGE FEE
OWNER"S PERMIT $ 1 00
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DES ED EXISTING DWELLING APPROVALS DATE INSPECTOR SSIGNATURE
TO THE PUBLIC S ER
SIGNED THIS DAY OF 19;0 NEW HOUSE SEWER 1-11
OWNER OR �� y� CONNECT ADDITIONAL -1-�- `„ L
OWNERS AGEN BUILDING OR WORK
ADDRESS f1'•'� SEPTIC TANK, SEEP, PIT(S)
AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I READ THIS APPLICATION ,CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE IS C RRECT 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 pISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT 1 At THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTI L ERTY BACKFILL SEPTIC TANKS❑
SEEP PIT(S) ❑ CESSPOOLS
SIGNATURE i /
OF PERMITT -
WILLIAM J. FOX.COUNTY ENGINEER VALIDATION
y BY _)�(Lo 7 � 9 BY� SEP 9 4 4.5 to
DEPUTY DEPUTY
'BY BY
® - DEPUTY DEPUTY