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DEPARTMENT OF COUNTY ENGIINF.ER SEWER-SEWAGE DISPOSAL
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELESBUILDING
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WILLIAM J. FOX, COUNTY ENGINEER I ADDRESS S9LZ /1/, 1_Ve1/y�T/S'
FAPPLIC T T FILL IN LOCALITY J�G
BUILDING ` NEAREST
ADDRESS CROSS ST.
/
LOCALITY DISTRICT NO. SERIAL N0. PERMIT N0.
. NEAREST A
CROSS ST. RECEIVE BY Heady for Ins0eclien CIA E ISSUED•
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OWNER /
MAIL USEZON OCCUPANCY Ali
ADDRESS BK PG
CITY , TE 10. ��S . G /J�
CONTRACTO CO.IMP.NO. / 3 /If t<-4::f
ADDRESS JOB.NO.
CITY A TRUNK PERMIT NO.
STATE
REGISTRATION N/ 7 COUNTY BAD PERMIT N0.
LEGAL &647
EENCROACHMENT
D ESCgIPTION LOT NO. P RMI N0.
BLOCK TRACT �yJ� IDUSTRIAL
`�� J` WASTE APPROVAL
SIZE OF LOT V %y.('RO.OF BLDG$. 7/ CHA EES
�/ NN O�W OO LUSE OF
OT L
BU II INGS T 6—'49"e. CONNECTION CHAq FEE
NO. DESCRIPTION OF WORK FEE
t REIMBURSEMENT FEE
N DOSE SEWER CONNECTING TO
PU BLIC SEW ER @ S 3.50 � J c-' RECEIPT NO. GATE IBY
N OUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM .1.00
CONNECT ADDITIONAL BLDG.OR EXCEPN RECORDED
WORK TO HOUSE SEWER 1.00 N0.
ALTER OR REPAIR EXISTING I DATE IBY
SEWER OR DISPOSAL SYSTEM 1.00 _
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1.00 CONNECTIO DATA
SEPTIC TANK,SEE P AGE PIT OR
PITS AND/OR DRAINFIELD 2.00 STATION 7f - /s Q DEPTH
CESSPOOL—ORYWELL / M12,75 ERENCE/�
SPECIAL CONDITIONS ONLY 2.00 G/ N4F �A
7 R/ hYWERa
TYPE OF CONNECTION LENGTH FR6M
V. CURB P.L. M.L.TO P.L.
OWNERS PERMIT f I OD 'rGNN ./� -LLEy
AUTHORIZATION TOTAL FEE
I HAVE THIS DATE WITH THE HEREIN NAED
CONTRACTOR TO CONNECT R THTE ED ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO TH PUBLIC SEWER
SIGNED THIS. �r-.....DAY OF _.. _J.. NEW HOUSE SEWER "Ck zo ck /-aQ-S4.
OWNER OR CONNECT ADDITIONAL
OWNERS AGE T_ BUILDING OR WORK
...._.. ._ ...._. . ._. _
SEPTIC TANK.SEEP.FIELD T(S)
ADDRESS..... ._ _ __I ..._ _.. ._ -. .. ._ AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE HAT I HAVE READ THIS APPLI• CESSPOOL Q DRYWELL E]
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 1 AM PROPERLY REGISTERED DISCONNECT PLUG AND
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNT
AND STATE OF CALIFORNIA OR THAT HE LEGAL OW ABANDON HOUSE SEWER
ER OF THE ABOVE DESCRIBED R NTIAL PROPERTY. BACKFILL SEPTIC TANKS _
/ SE EP.PIT(S)� CESSPOOLS
SIGNATURE
OF PERMITTEE... ... . _...._. .. . .-._ .. .. ..
7GA642A 663 7/53 /�