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R•09APPLICATION FOR PERMIT 1
aDILYISION OF BUILDING AND SAFETT SEWER—SEWAGE DISPOSAL
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County od Los jliy- ADDRQSG f' S
VV)&J. FOX, COUNTY IzNGINXKR
CA.SSATT M GRIFFIN,JSUYT OR BUILDING LOCALITY
FOR APPLICANT TO FII.L IN REARM
LEGAL
081 S'f
DESCRIPTION LOT NO. 4.1W0-P- q E/67 Y r OWNER C!
BLOCS: TRACT�t 1d� MAIL
MOIRES! I I I
SIZE Of LOT L O NOw ON LOTS `' JYJ7 71
CITY C Lo/ T[L X0. [�
USE OF
BUILDINGS I e21 DISTRICT X0. GROUP YAP
/ I 7[ PG
CONTRACTOR
ADDRESS CONNECTION DATA
CITY TEL. NO./, D 4PAg(OPP !`4STAnOII DEPTH
❑ STATE a LLANHOLK
UPPER REFERENCE 60iy�
REGISTRATION N0. ❑ COUNTY
TYPE OF CONNECTION LENGTH FROM
No. DESCRIPTION OF WORK FEE CURB M.L..To P.L.
HOUSE SEWER CONNECTING TO r•-y�
PUBLIC SEWER 3.30 J
HOUSE SEWER CONNECTING TO
PRI VATT DISPOSAL SYSTEM 1.00
XCONNECT ADDITIONAL BLDG. OR CO. IEP•NO. ,Z,,7 JOB. NO.
WORK TO HOUSE SEWER 1.00
ALTER OR REPAIR EXISTING
$EWER OR DISPOSAL SYSTEM 1.00 TRUNK PERMIT NO. ROAD PERMIT NO. Q
DISC XNECT AND ABANDON SEWER STATE ENCROACHMENT
,W
DISPOSAL SYSTEM 1•� PERMIT NO.
SEPTIC T1�NK,SEEPAGE PIT OR
PITS AXD/OR DRAIXFIELD 1.00 INDUSTRIAL
.CESSPOOL-DRYWELL WASTE APPROVAL
SPECIAL CONDITIONS ONLY 1.00 CHARGES
CONNECTION CHARGE FES
OWNE$'S $ 3 00
AUTHORIZATION TOTAL FEE O REIMBURSEMENT FSEI HAY
TRACTORTTOS DATE CONNECT THEA OVEWITH
DESCR BED El(ESTINQIN AMRDL D•WEI,LIOXG APPROVALS DAT$ INSPECTOR'S SIGNATURE
TO THE PUBLIC SEW
SIGNED THI AY OF 19- KEW ROUSE SEWEER
OWNER OR CONNECT ADDITIONAL -
OWNERS AGENT BUILDING OR WORK
r 8E C TAMC,SEEP PIT(S)
ADDRE9 AXD OR DRAIRFI LEI
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATI CESSPOOL❑ DRYYELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDIXANCFJ! AND STATE LAWS REGULATING ALTER, REPAIR,SEWER OR
PLUMBING AHD SEW RS
SEWAGE DISPOSAL IYSTYM
1 HEREBY CERTIFY THAT 1 AY PROPERLY REGISTERED AND/OR
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND -
CALIFORNIA OR THAT 1 AN THE LEGAL OWNER OF THE ABOVE ABANDON HOUSE SEWER
DESCRIBED REIIDEMTLAL PROPBaTY.
BACKY ILL 1 C TARS❑
!IT 1 CESSPOOLS
SIGNATURE
OF PERMITTEE
WILLIAM J. x. COUNTY KNOINLIM VALIDA7=-
9r 6 4 65
DEPUTY DEPUTY
BY 1Y • -199
m DEPUTY �/� , DEPUTY