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DEPARTAMiT OF COUNTY ENGINEER SEWER—SEWAGE DISPOSAL 1
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY EN13INEER ADDRESS
BUILDING
FOR APPLICANT TO FILL IN LOCALITY
BUILDING F6 NEAREST
ADDRESS CROSS ST. v e_ O-a
tc-
LOCALITY DISTRICT NO. SERIAL NO. PERMIT NO. C
NEAREST A IS`7 87D. J
CROSS ST. RECEIVED BY Ready for Inspeotlon DATE ISSUED
OWNER h
MAIL • a-L��Q_ �1��b 53
_ADDRESSIJ USEZONIk OCCUPANCY BK MAP PG
CITY TEL.NO. —4 M:
CONTRACTOR �^ (tis ty CO.IMP.NO.
ADD SS �/'f S JOB.N0.
CI Y \/ TEL.N07U•� ��` TRUNK PERMIT NO.
REGISTRATIO NO. f� COUNTY
ROAD PERMIT N0.
LEGAL STATE ENCROACHMENT
DESCRIPTION LOT NO. PERMIT NO.
BLOCK TRACT / ' INDUSTRIAL
WASTE APPROVAL
NO.OF BLDG .
SIZE OF LOT 70-13 1 NOW ON LOTS CHARGES
USE OF
-BUILDINGSSLy�¢- y� CONNEC CHARGE FEE
NO. DESCRIPTION OF WORKC, FEE
HOUSE SEWER CONNECTING TO REIMBURSEMENT F
PUBLICSEWER 13 @ $ 3.50 RECEIPT NO. T E IBY
HOUSE SEWER CONNEC ING TO
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.OR 11_01�1_ EXCEPTION RECORDED
WORK TO HOUSE SEWER: 1.00
ALTER OR REPAIR EXISTING • NO' I DATE IBY
SEWER OR DISPOSAL SYSTEM 1.00
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM - 1.00 I CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR /
a �
PITS AND/OR DRAINFIELD 2.00 I STATION V G• DEPTH
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 2 00 _ �,� I_ ANA REFERENCE
TYPE OF 0 ECTION LENGTH FROM ^O
OWNERS PERMIT $ I I Do M L.TO P.L. .G
-AUTHORIZATION TOTAL' FEES}`®
I HAVE THIS DATE CONTRACTED WITH THE HEROIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER
SIGNED THIS_ _----.DAY OF._��'��_---------------- 19_b� NEW HOUSE SEWER 5GhyQCie-
CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK
OWNERS AGEN ... ._ /�._ _
SEPTIC TANK,SEEP.PIT(S)
ADDRESS. AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE#AT I HAVE READ THIS APPLI- CESSPOOL E] DRYWELL Ej
CATION AND STATE THAT BOVE IS;CORRECT AND AGREE
TO COMPLY WITH ALL CO N ORDINANCES AND STATE LAWS ALTER,REPAIR,SEWER OR
REGULATING PLUMBI SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTI THAT 1 AM ± ROPERLY REGI E ED DISCONNECT PLUG AND
.AND/OR LICEN AS REQUIRED B LOS ANGELES NTY ABANDON HOUSE SEWER _
AND STATE OF CA IFORNIA 0 TN I AM THE LEG OWN-
ER OF THE ABOVE SCRIB R IDENTIA�L/PRO P TY. BACKFILL SEPTIC TANKS
SIGNATURESEEP.PIT(S)❑ CESSPOOLS
OFPERMITTE - --- -----------------. .....---....................--...... -
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