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DEPARTMENT OF COUNTY ENGINEER SEWER—SEWAGE DISPOSAL
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
WILLIAM J. FOX. COUNTY ENGINEER I BUILDING
ADDRESSFOR APPLICANT.TO FIL IN LOCALITY
ADOLD No 4
DRESS,!F NEAREST
CROSS ST.
LOCALITY DISTRICT NO. SERIAL NO. PERMIT NO.
NEAREST A /V /v �s
CROSS ST. / RECEIV BY Reedy for Inspection DATE IS UED
OWNER O 6 s
MAIL USE LONE OCCUPANCY BK MAP PO
ADDRESS OCCUPANCY
CIT�K.: �I�iC/J TELAO. Al—/ I�C� U / 1�Y� -,•✓
7
CONTRACTOR L� 'fo�M e L7 A� CO.IMP.N0.
ADDRESS `� FF- JOB NO. ., 3
CITY `-� f.es�l.A TEL.MODr OG,i 7c
TRUNK PERMIT N0. r
REGISTRATION NO. COUNTY ROAD PERMIT NO. Z4/-7
LEGAL y STATE ENCROACHMENT
DESCRIPTION LOT N0: /� •S� �S�• PERMIT NO.
BLOCK TRACT INDUSTRIAL `
- ' ,—I WASTE APPROVAL
*'
SIZE OF LOT /� rj�.N0 :00 SLOGS. N
�( NOW^NLOT CHARGES
USE OF
BUILDINGS CONNECTION CHARGE E
NO. DESCRIPTION-OF WORK FEE v
HOUSE SEWER CONNECTING TO REIMBURSEMENT FEE '
PUBLICSEWER a $ 3.50 RECEIPTNO. IATE BY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.OR CCEPTION-RERDEO
WORK TO HOUSE SEWER 1.00 �'
ALTER OR REPAIR EXISTING -- ^f/No- I GATE IBY
SEWER OR DISPOSALEXISTING
1.00
DISCONNECT AND ABANDON SEWER '
AND/OR DISPOSAL SYSTEM 1.00 CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR GRAINFIELD 2.00 STATION/0-70' 7J•/�-
3 DEPTH /O
CESSPOOL—ORYWELL
SPECIAL CONDITIONS ONLY 2.00 D / GMAN EFERENCE/� 1J
CJ G. �U PP�Eq // /J +nu1ca`
TYPE OF CONNECTION LENGTH FROM
OWNERS PERMIT $
1 00 III= M.L.TO P.L. .20
AUTHORIZATION I TOTAL FEE .'�- Sd '
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
SIGNED THIS..._....._..._...DAY OF------- NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT---------------------------------------- ------- BUILDINGORWORK
SEPTIC TANK,SEEP.PIT(S)
ADDRESS._........................................._.................._..._...___._......_. AND/OR GRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI- CESSPOOL� DRYWELLE]
CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO C041PLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER.REPAIR.SEWER OR
REGULATING PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED DISCONNECT PLUG AND
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY DISCONNECT
HOUSESEWER
ANO STATE OF CALIFORNIA OR THAT 1 AM THE LEGAL OWN-
ER OF THE ABOVE DE RIBED R 51 TIAL PRO ERTY, BACKFILL SEPTIC TANKS E]
SEEP.PIT(S)Q CESSPOOLS
SIGNATURE
..... ._.. .lr---,_-_
TOA642D 663 1/53 Q/