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DEPARTMENT OF COUNTY ENGINEER SEWER—SEWAGE DISPOSAL10.9® Z
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES ��
WILLIAM J. FOX, COUNTY ENGINEER BUILDING
I ADDRESS
FOR APPLICANT TO FILL IN LOCALITY CA _.
ADDRESS /� f� CROSS ST.NEAREST l /
LOCALITY DISTRICT N0. V8ERIAL NO. PERMIT NO. c
NEAREST r A / /06 S
CROSS ST. / ±L' �
L` RECEIVED BY Ready for Inspe14c`tion / DATEISSUED
OWNER ,
MAIL c
ADDRESS /kJ�/�/L�-, USE ZONE I OCCUPANCYBK MAP PG
CITY TEL.NO. l�
CONTRACTOR Cali fArnla Sewer Const.Co. CO.IMP.NO. 9
ADDRESS 1117 rolegrove Ave. JOB.NO.
CITY I�outebello TEL.NO.UNion 1-5048 TRUNK PERMIT NO.TE
REGISTRATION NO. 104445 SCANTY
ROAD PERMIT N0.
LEGAL
DESCRIPTION LOT N0. JW�' 9�f^��p STATE ENCROACHMENT
/% 4nCi a / PERMIT NO. `-
BLOCK Z3 TRACT �A� / v, WASTE APPROVAL
SIZE OF LOT?4,Ra X a2 76 NO.OF BLDGS.
f NOW ON LOT CHARGES
BUILDINGS CONNECTION CHARGE FEE
`
NO. DESCRIPTION OF WORK FEE REIMBURSEMENT FEE \ /
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $ 3.50 RECEIPT NO. I TATE` I BY
HOUSE SEWER CONNECTING TO
_ PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.OR EXCEPTION RECORDED\
WORK TO HOUSE SEWER 1.00
ALTER OR REPAIR EXISTING NO- I DATE I B
SEWER OR DISPOSAL SYSTEM 1.00
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1.00 CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR D_RAINFIELD 2.00 STATION �7L S44 DEPTH S-
-CESSPOOLDRYWELL / /�/
SPECIAL MANHOLE REFERENCE CONDITIONS ONLY - 2.00 YI!
sem LOWER
TYPE OF CONNECTIO LENGTH FROM 1 J
•1'— •e"" �.) M.L.TO P.L.
OWNERS
PERMIT $ I 1 00
AUTHORIZATION TOTAL FEE
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO THE PLIC SEWER
SIGNED THIS.-3o-..-.. Y OF...-----�'......--.. ..19. NEW HOUSE SEWER So OG k
OWNER OR CONNECT ADDITIONAL
OWNERS GENT..... ...... ----- ....... BUILDING OR WORK
w
SEPTIC TANK,SEEP.PIT(S)
ADDRESS .. .�t .. j ..... AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS AP I- CESSPOOL❑ DRYWELL
CATION AND STATE THAT THE ABOVE IS CORRECT AND AG EE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER,REPAIR,SEWER OR
REGULATING PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED DISCONNECT PLUG AND
AND/GR LICENSED AS REQUIRED BY LOS ANGELES COUNTY —ABANDON HOUSE SEWER
AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN,
ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS
SIGNATU �!r
. SEEP.PIT(8)� CESSPOOLS S� Yh�F+ ,
RE /D/
OF PERMITTEE---• L+---�---•-••---::•-.::a..-..------•--••--••-•---•--•�-•---- '
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