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-SEWAGE P®SADIVISION OF BUILDING AND SAFETY SEWER
DepozI ent of County Engineer
County of Los Angeles BUILDING
ADDRESS
WM.J. FOX, COUNTY ENGINEER
CABSATT D. GRIFFIN, HUP'T OF BUILDING LOCALITY
FOR APPLICANT TO FILL IN NEAREST
CROSS ST.
LEGAL .�
DESCRIPTION LOT NO. _ + OWNER
MAIL
6L,pGK TRACT �y�d�,� � / � h��L ADDRESS
SIZE OF LOT ✓(rsd NOW ON LOTS / CITY TEL NO _
USE OF
DI �� �y�'e J DISTRICT NO, GROUP MAP
BUILDINGS w(M�/Y►i�!{.?O�7 ,�j y, ,{�
&A RM
//°66We S 7 BK PG
CONTRACTOR
ADDRESS S a P M A hTA CONNECTION DATA
CITYC TEL. NO. Q� STATION �- DEPTH
14 RREGISTRATION NO 0" If q c COUNTY MANHOLE REFERENCE �Y / LOWER '
NO" DESCRIPTION OF WORK FEE
1HOUSE SEWER CONNECI ING TO TYPE OF CONNECTION LENGTH FROM a
-PUBLIC SEWER Q $ 3 50 Y M L TO P L
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00 _
CONNECT ADDITIONAL BLDG OR /-� P C NO.
WORK TO HOUSE SEWER 1 00 CO. IMP NO J JOB NO
ALTER OR REPAIR EXISTING Y /
SEWER OR DISPOSAL SYSTEM 1 00 TRUNK PERMIT NO ROAD PERMIT NO/On ( f/
DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT
AND/OR DISPOSAL SYSTEM 1 00 PERMIT NO
SEPTIC TANK, SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 2 00 INDUSTRIAL
CESSPOOL- DRYWELL WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2 00 CHARGES
CONNECTION CHARGE FEE
OWNERS PERMIT S 1 00
AUTHORIZATION I TOTAL FEE REIMBURSEMENT FEE
HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSI CTOR'S SIGNATURE-
TO THE PUBLIC S WER - A -
SIGNED THIS .-
-DAY OF 19� NEW HOUSE SEWER U
Or
OWNER OR0,0 CONNECT ADDITIONAL
OWNERS AGENT°� BUILDING OR WORK
ADDRESS�� ` SEPTIC TANK, SEEP, PIT(S)
AND/OR DRAINFIELD
IO ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER, REPAIR, SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM -
.1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR '
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE ABANDON HOUSE SEWER
DESCRIBED RESIDENTIAL PROPERTY, BACKFILL SEPTIC TANKS[; p�
t � e SEEP. PIT(S) ❑ CESSPOOLS[]"/ 'P ��. �1' r�'•,•�
SIGNATURE ./..� ,p
r vv
OF PERMITTEE ��O""�l -
WILLIAM J. FOX,COUNTY ENGINEER VALIDATION R.A.WOOD. CHIEF PLBG. INSPECTOR
L&6 6. 8 2 JUN 6 4 4.5 Q . �'