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BA84 fo-09 APPLICATION FOR PERMIT.
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COUNTY OF LOS ANGELES SEWER— EWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BVILDING AND SAFETY DMSION eulLnlNo �r/�
rr0ffi( A. LAM omM Cc= � •oc ADDRSSI �yY C.r
VV71.I.IA)[ A. T • Sup'f of �i�ldlnQ
LOCALITY
NEAREST
FORAPfLIPWT `"°" `TAl
[SCR L O I OWNER
MMA..O-R.F.11
OF ■SIZE OF LNOW ON LOT TEL. NO.
USI OF OUP MAF PROCLS ■Y
BUILDINGS ■K PGrCONTRACTOR s,(�, .r1 ADDR"S U G. A
CITY /EL NO. eTATINC[REGISTRATION NO. COUNO. DESCRIPTION OF WORK FEt [HOUSE SEWER CONNECTING TO P.LPUBLIC■EWER 55.00 � F.C.NO.
SKPTIC'fAp4K,SWPAGIE P OR CO,IMP. NO. Jq■NO.
PITS AND/OR DRAINF ILJD 510.00
OUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PXRMITFZ� 09
PRIVATE DISPOSAL SYSTEM O 95.00
CONNECT ADDITIONAL■ .OR AFFIDAVIT BiVtt<It LuffugST RECORD.IN NO. DATE O
WORK TO HOUSE NEWER $3.00 (Q�j
OVERFLOW SIEPA09 PIT,DRAINFI[LD
Kx_r N.,C XSSPOOL,DRYW[LL,MANHOLC O 55.00 H
AL R oIRABLANDoN
SEWER OR DISPOSAL SYSTEM $9.06 STATE[NCROACHMINT
4'ERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGX5
WNER PERMIT s 21 00
AUTHOF=nON I TOTAL FEF CONNECTION CHARGE FE[
'1 HAVE AT THISDATE A CONTRACT WITH THE HEREIN AMID CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DISCRIDED LXI■TING DW[LLING
TO THE PUBLIC SEWER. A.PPEOVAIS DATE IN E R'S SIGNATURE
SIGNED THIS DAY OF
OWNER OR NEW HOUSE SIWQ
OWNERS AGENT CONNECT ADDITIONAL
ADDRL/ BUILDING OR WORK
SEPTIC TANK.STEP,PITS)
1 HEREBY ACKNOWLIOOK THAT 1 HAVE READ THIS APPLICATION AND/OR DRAINFI"
AND STAT[ THAT THE ASOVI I■ CORRECT AND AGR[[ TO COMPLY
WITH ALL COUNTY ORDINANCE# AND STATE LAWS RIQULATING
PLUMBING AND SEWERS CESSPOOL Cl URYWILL ❑
I HERESY CERTIFY T 1 AM PROPIRL REGISTERED ANDVOR ALTER.REPAIR,■EWER OR
LICENSED AS R[ MY Lp1 OL[S UNTY AN ATI OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR AT AM TK
O E
L R OF, AN NTND TO DISCONNECT PLUG AND
REDID[ IN, ABO [k ED E IAL PR RTY. ABANDON HOUSE SEWER
SIGNATURETANKS ❑
OF PERMITTEE SAC KFIIT S[r�C
ew.PIr(e) Ll cEasPoou
f
A DATION ROBERT A. WOOD
M.o. CtiH SUPERVISING MECHANICAL ENGINEER
5 0 5 2;�S JAN 30 1 0 D 7,00~
r
10
76A, -w APPLICATION FOR PERMIT
AB4e4zD
COUNTY of Los ANGELES SEWER—SEWAGE DISPOSAL
DI;PARTMU T OF COUNTY ENGR=
B=ING AND SAFETY DIVISION BUILDING
JOHN & LAM M CO>mty Enyfn- ADDRESS
A. IE SM. sup'E Oi E 178 *.g
LOtA L STY
N[AR[ST
Epvtrl�
CANT, CROS. .T.
D[SCRI
OWNER
WAIL
BLOCKADDRESS
O GS.
SIZE OF LOT NOW ON LOT CITY TEL NO.
j USE OF DISTRICT NO. GROUPJ MAP
BUILDINGS BK PG
CONTRACTOR
ADDRESS /� �/'� CONNECTIOII VATR
r� ION DEPTH
CITY T[L. NO. +
■TAT= MANHOLE REFER
[NC
REGISTRATION NO. COUNTY [
NO. DESCRIPTION OF WORK FES TYPE F c N ION LENGTH FR0
HOUSE BEWER CONNECTING TO F.L Y.L.TO P.L
PUBLIC SEWER 0 65.00 F.C.NO. O
SEPTIC TANK,8KXPAQXrIT OR CO.IMF.NO. JOB NO. V
FITS AND/OR DRAINFIELD 510.Oo
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT �
PRIVATE DISPOSAL SYSTEM •5.00
CONNECT
ADDITION BLDG. AFFIDAVIT •IU/u W[S[IR RIC ORD. INSTR.NO. DAPI
WORK TO HOUSE BEWER $3.00
OVERFLOW SEEPAGE FIT,DRAINFISLD p„
KXTN..CESSPOOL.DRYWELL.MANHOLE $5.00 h
ALTER.R AI R A NDOHOUSE HWY.OR ST.WIDENING
SEWER OR DISPOSAL■ 3.00 STATE[NCRO H
PERMIT NO.
INDUSTRIAL
OWN�'8
WAIT[AFP ROYAL
CHARGES
�
. PEa�T.•rt�. •
AV HOiMATIO14 TOTAI. rLL CONNECTION CF{ARG[FIII
REIMBURSEMENT FSS
'1 HAVE AT THISRDATE A CONTRACT WITM THE HQIEIN NAMED CON- ��p
TACTOR TO COPINI
CCT THE ABOVE DESCRIBED GSISTING DW[CLING APPROVALS
TO THE PUBLIC SEWER. DATE INSPECTOR'■SIGNATURE
SIGNED THIS DAY OF 10_
OWNER OR NEW HOUSIE NEWER
OWNERS AGE Nt CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP,PIT(S)
' IC
ACKNOWLEDGE THAT I RAV[ READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AOR[[ TO COMPLY
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
I HEREBY C[RTI THAT I AM PROPERLY REGISTERED AMD/OR ALTER.REPAIR,SEWER OR
LICEN■[D AB R[ [D BY ON ANGLES COUNTY,^D STATIC OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA O 1 AM TH L,EGAL N[R OF D IHT[Np TO DIPLUG
HOPLUG AND
RESIDE IN, A VE D[SC [D [NTIA F F6 RTY. ABANDY■E SEW ER
SIGNATURE =7?1LL SEF16 TANKS ❑
OF FERMI SEEP.PIT(S) CESSPOOLS
A MATION ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
GK. M.O. CASH
V'o 5 0. 5 31-0 JAN 3 0 1 1 D 2 rj,0 0 F