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76A 642D-C'E808-10-71 APPLICATION FOR PE IT
' COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
• BUILDING AND SAFETY DIVISION BUILDING
ADDRESS 717
LOCALITY .+��'� C�7
FOR APPLICANT TO FILL IN NEAREST CROSS
CROSS ST
LEGALt �� �//���� �1
DESCRIPTION LOT NO �7E.r"E/k$�.. V L OWNER /
MAIL /
BLOCK TRACT ADDRESS
SIZE OF LOT
QOO NOWOON LOTLOGS CITY 6i� TEL. NO 292y�Z�
USE OF / DISTRICT NO GROUP MAP PROC SSED BY
BUILDINGS S
&0
q BK PG
CONTRACTOR� v /��C
ADDRESS off CONNECTION DATA
CITG� NO S�(�33/ STATION .t UPPER
4 DEPTH ,
STATE LIC MANHOLE REFERENCE
((((ErrFERE NC E_T
LICENSE NO CLASS LOWER
NO DESCRIPTION OF WORK FEE TYPE OF CONNECTION$! LENGTH FROM
HOUSE SEWER CONNECTING TO O Y CURB M L TO P L
PUBLIC SEWER @ $7.00 P C NO.
SEPTIC fANK.SEEPAGE PIT OR
PITS ANO/OR DRAINFIELD @ fl0 00 CO IMP. NO JOB NO
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO
PRIVATE DISPOSAL SYSTEM @ $300 O
CONNECT ADDITIONAL BLDG OR AFFIDAVIT M'AIVEE -EASEMENT RECORD INSTR NO DATE
WORK TO HOUSE SEWER @ $300 u
OVERFLOW SEEPAGE PIT DRAINFIELD •p�
EXTN CESSPOOL DRYWELL 0 $500 HWY.OR ST WIDENING O
.
ALTER,REPAIR OR ABANDON HOUSE _
SEWER OR DISPOSAL SYSTEM @ $300 STATE ENCROACHMENT W
MANHOLE $7 OO- PERMIT NO d
INDUSTRIAL H
WASTE APPROVAL Z
OWNERS PERMIT $1 3 00
CONNECTION CHARGE FEE CHARGES
AUTHORIZATION TOTAL FEE IFV]
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER APPROVALS DATE I CTOR'S IG NATURE
SIGNED THIS DAY 0 119
OWNER OR NEW HOUSE SEWER ` L
OWNERS AGENT
CONNECT ADDITIONAL
ADDRESS Y BUILDING OR WORK
SEPTIC TANK SEEP.PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING El AND SEWERS CESSPOOL DRYWELL
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR ALTER,RE PAIR SEWER OR
LICENSEDAS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT IAM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABOVE DESCRIBED RESIDE IAL PROPERTY. ABANDON HOUSE SEWER
SIGNATURE � _`
OF PERMITTEE r dj BACKFILL SEPTIC TANKS ❑
SEEP PIT(5) ❑ CESSPOOLS ❑
v . 77,57
VALIDATION CK. M.O. CASH
Q 4 415-v OCT 2 7 1 0 D 1 0,0 0!--
CQ
2"°
76A6A 6420/7
42D APPLICATION FOR PERMIT
6 '
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING �� �
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS � 14:/)
COLEMAN W JENKINS. SUPT OF BUILDING
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST
(PRINT OR TYPE ONLY)
LEGAL
DESCRIPTION LOT NO. / OWNER
I L D MAIL
BLOCK TRACT ADDRESS
NO OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL NO. 47
L�
USE OF
BUILDINGS S(N r DISTRICT NO. GROUP CLASS MAP PRO ESSED BY
}1I' BKK,r,+ pG
CONTRACTOR,()&�p�6� �GA,nr 60 -:r
( -)
ADDRESS tFLtOSS 7 Y,. CONNECTION DATA
CITY '� ��-[ NO 3STATION -/f �(.� \' DEPTH
STATE LICLc / J PPE
LICENSE NO. GLASS MANHOLE REFERENCE �a J
a• !(.J LOWER
NO. •DESCRIPTION OF WORK FEE TYPE OF CONNECTIOI�{�!"i LENGTH FROM
HOUSE SEWER CONNECTING TO Y CURB PC
M.L TOP L
PUBLIC SEWER @ $5 00
SEPTIC LANK SEEPAGE PIT OR P C.NO
PITS AND/OR DRAINFIELD @ SIO 00 CO. IMP. NO JOB NO �Z '
HOUSE SEWER CONNECTING TO TRUNK PERMIT NOROAD PERMIT NO d
PRIVATE DISPOSAL SYSTEM @ $300 O
CONNECT ADDITIONAL BLDG.OR =11E. "[AS[M[Ki RECORD INSTR NO. DATE
WORK TOHOUSE SEWER @ S3.00 U
OVERFLOW SEEPAGE PIT DRAINFIELD CZ
EXTN CESSPOOL DRYWELL MANHOLE @ 55 00
RlTEgr1lE• —FPS.'ABANDON HOUSE HWY:OR ST WIDENING O
SEWER @ S300 d D STATE ENCROACHMENT iU
PERMIT NO
CL
INDUSTRIAL Z
WASTE APPROVAL
OWNERS PERMIT s 00 CHARGES
AUTHORIZATION TOTAL FEE 6,100 CHARGE FEE
J
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRI ED EXISTING DWELLING
TO THE PUBLIC SEWER,gAPPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS ✓e' DAY OF 19
OWNER OR NEW HOUSE SEWER
OWNERS AGENT
CONNECT ADDITIONAL
ADDRESS
BUILDING OR WORK
_
SEPTIC TANK.SEEP.PIT(S)
IH
ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL El El
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN THE ABOVE- D ESCRIBEO RE IDE .IAL PROPERTY ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS
OF PERMfTTEE SEEP PIT.(S) ❑ CESSPOOLS(❑
VA ATI pl'- JACK R. ALLEN
CK
SUPERVISING MECHANICAL ENGINEER
M O CASH
LAGo!1 �h y.;' JUL 1'g) 10 D 6.00-
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