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DEPARTMENT OF COUNTY ENGINEER SEWER-SEWAGE DISPOSAL 1
DIVISION OF BUILDING AND` SAFETY -PERMIT APPLICATION
COUNTY OF LOS ANGELES y,�I
WILLIAM J. FOX, COUNTY ENGINEER I BUILDING
ADDRESS
LITY
NG
FOR APPLICANT+CANT TO F LL IN PCABUILDI
ADDRESS iCR SS ST.
DISTRICT NO. (f SERIAL NO. PERMIT NO.
LOCALITY J
� A ��� c
NEAREST �_ ,�7_/�� - /L//,
CROSS ST. ,��"' eG� /L/'
y RECEIVED BY Ready for Inspection, DATEQISSUED
OWNER W
MAIL � I USE ZONE OCCUPANCY MAP
ADDR SSffoe. I 16 �` I BK PG
CITY TEL.NO. �� 1
CONTRACTOR ���1 �y �.��
�yCO.IMP.NO.
ADDRESS JOB.NO.
CITY �T^E1410" � TRUNK PERMIT NO.
STATE
REGISTRATION NO. ,.. p COUNTY ROAD PERMIT NO.
LEGAL DESCRIPTION LOT NO. / STATE ENCROACHMEN
PERMIT NO.
BLOCK TRACT ,,If11 S / DUSTRIAL
WASTE APPROVAL y
SIZE OF LOT f j l� U NOON LOT
W ( CHARGES
USE OF
—BUILDINGS CONNECTION CHARGE FEE
NO. DESCRIPTION OF WORK /-FEE
HOUSE SEWER CONNECTING TO / _yy REIMBURSEMENT FEE
PUBLIC SEWER $ 3.50 (/ RECEIPT NO. I �DA7E"_`I BY,
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.OR /EXCEPTION RECORDED �+
WORK TO HOUSE SEWER .1.00N0. DATE BY
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1.00 CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 2.00 I STATION Q 7/—eg DEPTH
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 2.00 I MANHaOLLE RREFERrC!2 U'ME LOWER
TYPE OF CONNECTION LENGTH FROM
1F: CURB_ P.L. M.L.TO P.L.
OWNERS PERMIT ; � t 00-,
AUTHORIZATION -I TOTAL FEE I
1 HAVE THIS DATE CONTRACTED WITH THE HEREIN-N'�A�ED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED�EXIss iNG APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER,—
NEW HOUSE SEWER
SIGNED TH.IS---\ -----mo- Y�-----•---:.------_------•----------�t .--- .�
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT_-___.._. - BUILDING OR WORK
SEPTIC TANK,SEEP.P-IT(S)
ADDRESS _-------------•- -- - AND/OR DRAINFIELD
•I HEREBY(ACKNOWLEDGE THAT I HAVE READ THIS APPLI- CESSPOOL I] DRYWELL
CATION AND STATE THATJTHE ABOVE IS CORRECT AND AGREE
TO COMPLY WITH ALLACOUNTY ORDINANCES AND STATE LAWS ALTER,REPAIR,SEWER OR
REGULATING,PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY`.CERFIFY THAT I AM PROPERLY REGISTERED DISCONNECT PLUG AND '
AND/OR LICENSED ,AS REQUIRED- BY LOS ANGELES COUNTY ABANDON HOUSE SEWER.
AND STATE,OF VE DERNIA R THAT 1 AM L PROPERTY.
OWN-
ER OF THE ABOVE DESCY!/RAJ,BED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS
_ . _-1 �j O , SEEP.PIT(S)E] CESSPOOLS C]SIGNATURE 1� ��((��
OF PERMITTEE.-----f ----/----- - -.._.__-_ ... - -
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