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E808 5-65 APPLICATION FOR PERMIT //
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COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILD
JOHN A. L1mlil E, Coup, Engine,, ADDRE55�J
COLE,NIAcN IT. JENAIINS.Supt. .1 B61,1mg IfLOCALIT
A
NEAREARE ST
FOR APPLICANT TO JF'IILL RQ `R1`°5 5T. ca -
DESCRIPTION LOT NO. �Q/l / / OVINE
MAL
I
BLOCK TRACT C'/J EL.,7
FAIL
NO. OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL, NO.
USE OF DISTRICT NO. GROUP MAP PROCESSED BY
BUILDINGS BK `PG-9
CONTRALTO_F
CONNECTION DATA
Y EL. NO O I�/O STATION .� V DEPTH
LICENSE AyO/y LICENSE /� MANHOLE REFERENCE
NO. DESCRIPTION OF WORK FEE TYPE OF E ION LENGTH FROM
ROUSE SEWER CONNECTING TO Y. CVRD P.L. M.L.TO P.L.
PUBLIC SEWER C $ 5.00 p
5 PT C'BAANK' SEEPAGE-- OR CO.IMP.NO. �J JOB NO. d
PIT5 ANO/OR ORA INFIELD F $I O.00 O
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMITu
PRIVATE DISPOSAL SYSTEM e^ 5 3.00
CONNECT ADDITIONAL BLDG. OR AFFIDAVIT nIY EYS[N ENL RECORD. INSTR,N°. DATE
WORK TO HOII E 5EWER C S 3.00 R Ep O
A'[T@—Tr�A 9 N ROUSE
SEWER OR DISPOSAL SYSTEM E $ 3.00 WWV
TL- HWY.OR ST.WIDENING d
E%TN.,CESSPOOL, MANHOLE 0 $ 5.00 N
STATE ENCROACHMENT z
PERCOLATION TEST c $ S.00 PERMIT NO,
INDUSTRIAL
WASTE APPROVAL
CHARGER
OWNERS PERMIT s z o0
AUTHORIZATION TOTAL FEE O CONNECTION CHARGE FEE
'1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. REIMBURSEMENT FEE
TRACTOR TO CONNE THE ABOVE d RIBED EXISTING DWELLIN APPROVALS
TO THE PUBLIC BE DATE INSPECT R'S SIGNATURE
SIGNEDAY OF24� 19 h
OWN ERO NEW HOUSE SEWER ✓'
OWNERS AG- CONNECT ADDITIONAL
BUILDING OR WORK
DORE55
SEPTIC TANK.SEEP,PIT'S)
HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION AND/OR DRAINFIELp
AND STATE THAT THE ADICORRECT AND AGREE COMPLY
WITH ALL COUNTY ORDINAINA NCEE S ANO STATE LAWS REGULATING
PLUME
ING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
1HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/Oft ALTER.REPAIR,SEWER OR
LICENSED AS REOUIRED Y LOS ANGLES COUNTY AN STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT THE ANGLES
OWNER OF. INTEND TO DISCONNECT PLUG AN
RESIDE IN, THE ABO ESCR D RESI ENTIAL P RTY. ABANDON HOUSESEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑ /` / ~
OF PERMITTEE SEEP.PITIS' ❑ CESSPOOLS
VALIDATION
CH. M.0.
LAIo 1 9 1 4:o MAY 10 1 0 D 7.00—