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DEPAUTMENT OF COUNTY ENGINEER SEWER-SEWAGE DISPOSAL
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
IWILLIAM J. FOX, COUNTY ENGINEER BUILDING ADDRESS
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FOR APPLICANT�JO FI�LLJ ILOCALITYBUILDINN p
ADDRESS t� /y ��" C'���t �..7 CROSS ST s��(�►-,� �g�p �/+4r
LOCALITY -y-' DISTRICT NO SERIAL NO PERMIT NO
f _ ,j A 11®94 ,6 S
NEAREST
CROSS ST �� d Q ECEIVED BY Ready for Inspection DA E ISSUED t,
OWNER` 'USE/T._ r /— 3—J` ,
MAILADDRESS ,{ d � OCCUPANCY BK MAP PG
CITY TEL NO.
CONTRACTOR i CO IMP NO
ADDRESS .2 /!E-- y4a-CA
JOB NO
CITY A126 EL N0. -7lp 7 TRUNK PERMIT NO
STA
REGISTRATION NO ROAD PERMIT NO tr/
LEGAL STATE ENCROACHMENT
DESCRIPTION LOT NO L° �' G9 PERMIT NO
BLOCK TRACT ' r �(� INDUSTRIAL
NO OF BLDGWASTE APPROVAL
SIZE OF LOT Ic �/ Cr N,O,Wf 0NN'•LOTS CHARGES
BUE DINGS ,SOF wGL�< 6'+✓C�-+ CONNECTION CHARGE%F E
NO DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO REIMBURSEMENT FEE
PUBLIC SEWERC� S 350 ��� RECEIPT NO. ��� Dit!E I BY
HOUSE SEWER CONNECTING,TO
PRIVATE DISPOSAL SYSTEM 1 00
CONNECT ADDITIONAL BLDG OR py EXCEPTION RECORDED
WORK TO HOUSE SEWER 100 l.�
ALTER OR REPAIR EXISTING NO DATE I BY�
SEWER OR DISPOSAL SYSTEM 1 00
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 100 CONNECTION DATA
SEPTIC TANK.SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 2.00 STATION Q 9� ��. DEPTH
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 200 MANHOLE REFEREN E
-Uaax8 jvae ;!, (A)&./ LOWER
TYPE OF CTION LENGTH FROM p /
OWNERS PERMIT = I 00 Y CURB P L ML TO P L
AUTHORIZATION TOTAL FEE
1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER 19�j]
NEW HOUSE SEWER �S
G-- ,
SIGNED THIS _s _�QAY _ —__ ___
OWNER OR JJ CONNECT ADDITIONAL
OWNERS AGENT _ _ _ BUILDING OR WORK
/__ l SEPTIC TANK,SEEP.PIT(S)
ADDRESS
'`--r �� AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI- CESSPOOL E] DRYWELL
CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER,REPAIR,SEWER OR
REGULATING PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED DISCONNECT PLUG AND
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOUSE SEWER
AND STATE OF CARNIA OR THAT I AM THE LEGAL OWN-
ER OF THE ABOVL" CRIBED SIDEN IA PR ER Y. BACKFILL SEPTIC TANKS n
Jy� SEEP PIT(S)� CESSPOOL$
SIGNATURE _ E ��= -
OF PERMITTEE _
76A642A 663 7/53