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DEPARTMENT OF COUNTY ENGINEER SEINER-SEWAGE DISPOSAL 1
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
WILLIAM D.
8"7/ry FOX, COUNTY ENGINEER I ADDRESS
' CAHHATT D. GRIFFIN, $UP'T OF BUILDING �
FOR APP ICA T TO FILL IN LOCALITY i�IlY� -(w �y� h
BUILDING NEAREST /(�� /" ��
ADDRESS CROSS ST. &.4s� ,/ R - �-
LOCALITY DISTRICT NO. SERIAL 1NO. PERMIT NO.O. c
NEAREST~ A "� < —e! S
CROSS ST.
R-ECE�VE R�eady�or Inspection DATE ED
OWNERMAIL /V.�t''/
ADDRESS �7 USE ZONE OCCUPANCY MAP-
/ 'y I Alzo, I BK�><
T
CITY EL.NO.
CONTRACTORCHAR, E SEME
REIMBURNTFEE
U4 s
ADDRESS 2 Sot �'�� zo �/ REQUIRED
�� NOT PEQU,I•RE- _
CITY ``� TELA61����1�.R� Cy 1j JOB NO. FZ- 0� CONNE ON CHARGE FEE'
REGISTRATION NO!�y'`gg ` 7/QOUANTY CO. IMP-.NO-"'�"��
LEGALRECEIPT NO. I DATE
DESCRIPTION LOT NO./ee-�;r
BEOCK TRACT,' ��i�� WAIVER_F.OR°RECORDING
SIZE OF LOT N0.DF BLDGS. RECEIPT N0. DATE I BY
Ij�� NOW ON LOT_ 1
USE OF ��
BUILDINGS TRUNK PERMIT NO.
N0. DESCRI I.ON T'OF WORK ' FEE'
�I HOUSE SEWER CONNECTING TO ROAD PERMIT NO.
PUBLICSEWER @ $ 3.50
HOUSE SEWER CONNECTING TO STATE ENCROACHMENT ey'f'�"
PRIVATE DISPOSAL SYSTEM 1.00 PERMIT NO. �'-
CONNECT ADDITIONAL BLDG.OR INDUSTRIAL
WORK TO HOUSE SEWER 1.00 WASTE APPROVAL
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM 1.00 CONNECTION.DATA
DISCONNECT AND ABANDON SEWER I A
AND/OR DISPOSAL SYSTEM 1.00 I STATION f%e+ DEPTH
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 2.00 I MANHOLE REFERENCE
EP-ER `
OWER ( >
CESSPOOL—DRYWELL Um
SPECIAL CONDITIONS ONLY 2.00 TYPE OF CONNECTION LENGTH FROM �}F
1V w CURB- P.L. M.L.TO P.L. y E
OWNERS PERMIT $ I 1 �00r�
AUTHORIZATION [TOTAL-FEE
ED
CONTRACTOIR TO CONNECT THDATETE ED ABOVE D SCRIBEDWITH THEI EXISTING APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER ��/
DAY OUSE SEWERSV
SIGNED THIS = -•--•------------•-- I UUs"L l U v�� �' '�
-`
{ CONNECT ADDITIONAL
OWNER OR f / ' BUILDING OR WORK
OWNERS AGS J-lJ�' .-._- _--------------------- - - SEPTIC TANK,SEEP.PIT(S)
ADDRESS--------------------------------------------------------- AND/OR DRAINFIELD
! HEREBY ACKNOWLEDGE THAT 1 HAVE,READ THIS APPLI- CESSPOOL❑ DRYWELL 0
CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS 'ALTER, REPAIR SEWER
REGULATING PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
-
HEREBY HEREBY CERTIFYpTHAT I AM PROPERLY REGISTERED DISCONNECT PLUG AND
AND/OR LICENSED REQUIRED BY LOS ANG LES COUNTY, ABANDON HOUSE SEWER
AND STATE OF CALI ORNIAIJR THAT I AM THL GAL OWN-
ER OF THE ABOVE ESCR D RESIDENTIAL PR PERTY. - BACKFILL SEPTIC TANKS El
SEEP.PIT(S)E] CESSPOOLS
SIGNATURE ,
OF P E R M I T,T LE-------7......................... .........---------------------------
76A642D 663 12/52'