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78A 612D-CESOO-10-71I '
APPLICATION F ��RMI ILJI
COUNTY OF LOS ANGELES SEWER-SE GE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION ■UIL' NG
,�DDRFJIlea) J-I�e LOCALITY C-
FOR APPLICANT TO FILL IN CROS■ ST.DESCRIPTION LOT NO. OWNER OP SMAIL
BLOCK TRACT VC ADD— S LL �r O QOF ■LDG■.+IZE OF LOT NOW ON LOT fT-'R
d TIL. No,USE OF . ■ROUP MAF PR KSBED
■OILDINO■ ■K' PS
CONTRACTOR E .ADDRX" C.ONNECTIO DATA
DEPTHCITY TILL 1{O.■TA+i EFERENCE LICENSE NOSLOWER
NO. .D"CRIPTION OF WORK FEE F CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO CUR■ P.L M.L.TO P.L.
PUBLIC■rw[R 0 $7.00 F.C.No.
■ FS C•7AN K.S P OF P oft JOB NO.
PITS AND/OR DKAINFIrLD >IOAOO ■ SEWER CO ECTING TO MIT N NO.PRIVATE DISPOSAL SY/aM SS.06 O
CONN CT ADDITIQNAL■ G.O ■M;: tA10[I7 RECORD.INSTR.NO. V
WORK TO HOUSX-SXWKR $7.00
OVERFLOW SEEPAGE PIT.DRAINFiELD O
KX-r N..CEISPOOL.DRYWELL.' $3.00
AL Uf HWY.OR ST.WIDENING
■EWER OR 61----&-ySTK 43.00 STATE ENCROACHMENT
MANHOLE $7.00 PERMIT NO. a
INDUSTRIAL
WAIT[APPROVAL
•
aWNER"S PERI41T i CHARGES
CONNECTION CHARD[FI[
ADTHOHIZATION TOTAL FEE
I HAVE AT TS DATE A CONTRACT WITH THE, HEREIN NAMED CON- REIM■U RIIM[NT F[[
HU
TRACTOR TO CONNECT TH ALO V[ DESCRI■[D EXISTING DWELLING APP
TO THE PUBLIC AEW APPEO I� DAT[ Imer-ECTOR'S SIGNATURE
SIGNED.THFB DAY OF Lp2j(o
OWNER OR NEW HOUSE SEWER A0 0
OWNCRI AGENT CONNECT ADDITIONAL
ADDRESS (� BUILDING OR WORK
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APT),IGATION SEPTIC TANK.SEEP.PIT(f)
AHD/QR QRAINFIELD
AND STAT[ THAT THE L
ABOVE IS CORRECT AND AGREE TO COMPY
WITH ALL CQUHTY ORDINANCES AND (TATE LAWS PEOULATING �y
or
PLUMBING AND SEWERS, CEBSPOOL ❑ QRYWELL LJ
I HEREBY CERTIFY THAT 1 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 I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
REIIpE IN, THE ABO DESCRISED RESIDENTIAL PROPERTY. ABANDON HODS[SEWER
SIGNATURE BACKFILL SEPTIC TANKS
OF PERMTTTEE SEEP.PIT(S) ❑ CEf{POOLS
VALIDATION CK, ►(.O. CATH
069r--Fo 9.00
� � p
DEPAIC13WENT OF COUNTY ENCaNEER SEWER—SEWAGE DISPOSAL 1
DMSION OF BUff-DING AND SAFETY PERMIT APPLICATION
COUNTY OF IAS ANGET,
NG
WILLIAM Jr FO , COUNTY ENOIINE[R ADDDRE ADDRESS
�•
FOR APPLIMIT TO HLL IN LOCAL'
BUILDING NEAREST
ADD EBB,, � e7rq cy��pv� CROSS 8T.
LOOALITY� ` � U DISTRICT N0. SEHIAL NIL PERMIT NO.
� A ,� - S
NEAREST
ORbBi CEIVED BY Ready fir I"veatlo■ DATE ISSUED
OWNER /1 '37rAIL
_ S
ADDRESS /Q f�Lr< rj Gee USE ZO OCCUPANCY BK YAP
S PB
CITY TELNO. /� �- l
CONTRACTOR p ;J 4 o OO.IMP.NO.
ADDRESS �, J013 N0.
CITY 1 TELNO f 60�/ TRUNK PERMIT MO. ^�
ATE
REGISTRATION NO. COUNTY ROAD PERMIT NO.
LEGAL
DMRIPTIOY LOT NO. 3 n 5p �d r STATE ENCROACHMENT
-- PfiRMIT NO.
BLOCK TRAOTR!_S I
WASTEINDUSTRIAL
APPROVAL
SIZE OF LOTN0.OF BLD98
MOW ON LOT I OHARig ES
USE OF
BUILDINGS �•//��� 00NNEOT7RBE FEE
NO. DESCRIPTION OF WORK FEE REIMBURSEMENT FEE
HOUSE SEWER 00 NEOTING TO
PUBLIC SEWER 40 If 6-6G no RECEIPT NO. BY
HOUBt IIIEWERCONNECTING TO
PRIVATE DISPOSAL SYSTEM IJNI
CONNECT ADDIT ONAL BLIDIL0 EXCEPTION RECORDED
WORK TO HOUSE&EWER 1.00
REPAIRALT9R 6k N N0. F DATE BY
SEWER OR DISPOSAL SYSTEM IAB
ISCOMNEOT AND A13AN66N SEWER
AND/OR DISPOSAL SYSTEM L" CONNECTION DATA
SEPTIC TANK,8EEPA4E PIT Ok
PITS AND/OR DRAINFIELD 2.00 STATION I�� DEPTHCESSPOOL—DRYwELL g
SPECIAL CONDITIONS ONLY 2.00I M fi0 ¢FERENCE
if Tim PP
TYPE OF CONNECTI LENGTH FROM r�
OWNERS PERMIT ; 1 00 C=L M.L TO P.L.
AUTHORIZATION TOTAL FEE 114 D
1 HAVE THISDATE CONTRACTED WITH THE HEREIN NAMED
CONTRAOTOR TO CONNECT THE ABOVE D96CRIBED EXISTING APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER
SIGNED THIS /h DAY OF //]] 19 f� NEW HOUSE SEWEB ScQ—
CONNECT ADDITION
OWNERS ABENT�'�_t � /l'J BUILDIN13ORRKWORKAL
ADDRESS �� �� ''` � AND EPTIOR DfWMFIELD TT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ TH18 APPLI- OEUP00L[] DHYWELL
CATIONAND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER REPAIR jEWER OR
REGULATING PLUMBING AND SEWERS. SEWA9E DIVO L SYBTEE
I HEREBY OERTIFY THAT I All PROPERLY REGISTERED D1800NNEOT PLUG AND
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOUSE SEWER
AND STAT[ OF CALIFORNIA OR THAT I AY THE L¢BAL OW -
ER OF THE ABOVE DESCQIBED VWENITI PROPERTY. IBACKFILLSEPTIO N
SIGNATURE SfiEP.P[T(S)E] CESSP00
OF PERMITTE
T6A642A 60 T/63 f /
/ / r