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CE80610-63 APPLICATION FOR PERMIT " '���/�c~,�°�ara ''
76A642D
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County Engineer ADORES
WILLIAM A. JENSEN, Supt of Building C
LOCALITY 7
NEAREST /M n J
FOR APPLICANT TO FILL IN CR055 ST. '�J•] r
AL
DESCRIPTION LOT NO: /r��---L OWNER ���„v
/`-. S G.O- (' MAIL �®I Ile
BLOCK TRACT ADORES �•
NO. OF BLDGS. '�
SIZE OF LOT NOW ON LOT CITY / . �• TEL. NO.
USE OF � , DISTRICT NO. GROUP
BUILDINGS MAP PROCESSED BY
PG
CONTRACTOR /Z ��� `7/ `”O 1IV
ADDRESS J6ff -� 41,WE �ZQ CONNECTION DATA
CITY TEL. NO. -7-' 04777 CSTATIO DEPTH
�y ❑ STATEMANHOLE REFERENCE// 5M /
REGISTRATION NO. ( a ❑ COUNTY LOWS
NO. DESCRIPTION OF WORK FEEY E OF N LENGTH OM
HOUSE SEWER CONNECTING TO Y. P.L. M.L.TO !L. �0 r
PUBLIC SEWER @ $5.00
SEPTIC TANK,SEEPAGE PIT OR / 'l� P.C.NO. O
PITS AND/OR DRAINFIELD @ 510.00
CO.IMP. NO. / a JOB NO. U
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. A ,�/ ix
PRIVATE DISPOSAL SYSTEM @ $3.00
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT I WAIVER EASEMENT �RrCOBD.-INSIR.„N O. DATE 1...,
WORK TO HOUSE SEWER @ S3.00 L)
OVERFLOW SEEPAGE PIT,DRAINFIELD LU
EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $5.00 yy a
ALTER,REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENIILG L�
i
SEWER OR PISPOSAL,SYSTEKI @ $3 O STATE ENCROACHMENT
PERMIT NO. ✓'reL'(,i�L-
INDUSTRIAL /� �••. �„_
WASTE APPROVA
CHARGES
C,OWNER'S PERMIT $ 2 00
AUTHORIZATION TOTAL FEE -7 &yr'f CONNECTION CHARGE FEE
v V n
'I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING 4V
TO THE PUBLIC SEWER. APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY QF 19_
OWNER OR /,�///� NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS 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
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COU TY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER F, AND INTEND TO FISCONNECT PLUG AND
RESIDE IN, THE ABO RISE S1 SIDENTI PROPERTY. BANDON HOUSE SEWER
SIGNATURE
ERMITTE - �� ' EEP,SACKFP PIT(S)
TANKS
CESSPO❑OLS ❑
l I
VALIDATION ROBERT A. WOOD
(� SUPERVISING MECHANICAL ENGINEER
CK. M.O. CASH
1 3 7 0 E JUL 15 1 0 0 7.00- p)
P1
,0-63
76AG42D APPLICATION FOR PERMIT
6A64V
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION FDR
o
JOHN A. LAMBIE, County Engineer
WILLIAM A. JENSEN, Sup't of Building
FOR APPLICANT TO FILL IN
LEGAL ��� aA��'
DESCRIPTION LOT NOWNER
O. Cel.!^- 4�S/
J 45) -1 MAIL e / -1
1
BLOCK TRACT ADDRESS y � J�i a
OS
SIZE OF LOT NOW ON LOTCITY p oC TEL. NO.
USE OF �(� DISTRICT NO. GROUP MAP PROCESSED BY
BUILDINGS .I.
�y /�' BK PG
CONTRACTOR � � e,r4f `�I ��
ADDRESSS H/ W sq aij�� CONNECTION DATA
STATIC, - DEPTH 9
CITY CJa T.L.
STATE UPPER
REGISTRATION.NO. ❑ COUNTY MANHOLE REFERENC p LOWER
NO. DESCRIPTION OF WORK FEE OF C-NN CT ON LENGTH FFfbM
HOUSE SEWER CONNECTING TO Y. P.L. M.L.TO P.L. �j' }
PUBLIC SEWER @ $5.00 P.C.NO. (L
SEPTIC TANK,SEEPAGE PIT OR CO.IMP.NO. r �Sp JOB NO. O
PITS AND/OR DRAINFIELD @ $10.00 l (�
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO, 6.'{�, (�
PRIVATE DISPOSAL SYSTEM @ $3.00 _ a� �7 LLQ
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE O
WORK TO HOUSE SEWER @ $3.00 V
OVERFLOW SEEPAGE PIT,DRAINFIELD -
EXTN.,CE55POOL,DRYWELL,MANHOLE @ $5.00
ALTER,REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING .A�„f` . ,L� 2
SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHMENT
�` PERMIT NO.41= 25.
(rV INDUSTRIAL p nw�
WASTE APPROVAL
CHARGES
OWNERS PERMIT $
AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEE
'1 HAVE 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 INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR /�p� NEW HOUSE SEWER
!
OWNERS AGENT v "� CONNECT ADDITIONAL ^ /wP
BUILDING OR WORK �1.,"✓I/r"
ADDRESS SEPTIC TANK.SEEP,PIT(S)
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL El DRYW ELL ❑
IHEREBY 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 6^M THE LEGAL OWNER OF, D INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABO DESCRIBED ENTIAL OPERTY. ABANDON HOUSE SEWER
SIGNATURE
ElBACKFILL SEPTIC TANKS
OF PERMITTE� SEEP,PIT(S) ❑ CESSPOOLS ❑
VALIDATION ROBERT A. WOOD
��°J SUPERVISING MECHANICAL ENGINEER
CK. M.O. CASH
LACO 1 3 7 2-w JUL 1 5 1 1 D - 2 5.00' 4