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78A APPLICATION FOR PERMIT
QA 8*Z64213
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION FLO.0
LDING
JOHN A. LAMIBIE. CouN-ry ENGINEER Rw
C11-
COLEMAN W. JENKINS. SUPT. of BUILDING ;F-O ALITY
N[CREST
N TO PILI.., IN ci�oBB /r.
(PRINT OR TYPE ONLY)
LZOAL
[STATE
/CRIFTION LOT NO. OWNER
MAIL
OCK TRACT ADDRw
NO. OF /4-1343■. All 9/
E OF LOT NOW ON LOT CITY
E OF DISTRICT N0. SROUP CLA3f MAP PR Df FD BY
BUILDINGS ■K
NTRACTOR Q4 s
DRESS COMM ON DATA
Y TEL NO STATION DETTH
LIC (`J�! `J WANHOL[RKMPMNC[ U
[N/[ NO. GLAL� ♦ LOW
NO. DF-SCRTPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CU RX P.4- M.L TO P.L
PUBLIC SEWER 0 /5.00 V P.C.NO.
S IC TANK,S P 43[ OR A 1-Yr JOB NO.
PIER AND/OR DRAINFIKLD 0 310.00 CO.IMP.NO.
HOUSE SLWCR CONNECTING TO TRUNK FLIMTT NO. ROAD PQtMIT NO.
PRIVATE DISPOSAL SYSTEM $3.00 O
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT •AIF[■ 'LAtt Rt%T RECORD.INBTR.NO. DATE V
WORK TO HOUSE SEWER 33.00
OVERFLOW/[[PAGE PIT.DRAINFIELD OL
EATN..CISSPOOL,DRYWffLL.MAN H OLE $3.00 O
A R.R A R A O O HWY. OR B'T.WIDENING
SEWER OR DISPOSAL SYSTEM 3.00 STATE ENCROACHMENT
PERMIT NO. a
INDUSTRIAL
WASTE APPROVAL Z
0WNm'3 PE Mft s 00
CONNECTION CHARD[FE[ CHARGES
AUTHOBMTION TOTAL FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIIISURSEM[NT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED E7SILTING DWELLING It�7 Ta
TO THE PUBLIC f[W R. APPEOWIS DATIE INSPEC'TOR'S SIGNATURE
SIGNED THIS PjxY Iti_ I
OWNER OR NEW HOUSE S%W[R i
QWNERS AGENT CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
I HERESY ACKNOWLEDGE THAT I READ THIS APPLICATION SEPTIC TANK.■EIPIT(S)
AND/OR DRAINFI[LD
AND STAT[ THAT THE ALQV[ If CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINA NCp AND STAT[ LAWS REGULATING
FLU MBING AND Srw ERG. CESSPOOL ElDRYW[LL ❑
I HEREBY CERTIFY AT I AM PROPIRLY REGISTIR[D AND/OR ALTER,REPAIR.SEWER OR
L IC[N2KD AS R[OUI BY LOS ANGLES COUNTY AND STATE OF ■EWAGK DISPOSAL SYSTLM
CALIFORNIA OR YHA AM TH[ LMOAL N[R OF. AND INTEND TO DISCONNECT PLUG AND
R[SI D[ IN, EH[ A [ DEiCRI NTIAL PROPERTY. ABANDON HOUSE SEWER
SIGNATURE
OF P[RM E /ACK FILL /'L� L
I crJaroou �/1
ATION JACK R. ALLEN
SUPERVISING MECHANICAL ENGINEER
CK. M.O. CASH
, -+141 0 0 10.00-
DF.PA CTIFI NT OF COUNTY ENQIQMCR SEWERr--SEWAGE DISPOSAL 1
DIVISION OF BUELDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGIMER
WILLIAM J. FOX, =UNTY ENDINIEM BUILDING
ADDRESS
FOR APPLICANT JQ RLL IN L0OALrTy
BUILDING `� / WasT.
ADDRESS (� aOIR�f1EEedlS1TT
LOOALITY DMTIVOT M(L SERIAL NO. PERMIT MO.
NEAREST S A SS
CROSS ST.
Ria ED iaftfirl�■ DATIISSUED
OWNER -// - 3
■AIL
ADDRESS USE ZONE 0O0UPANCY MAP
BK PG
CITY TELNO. -
CONTRACTOR P.N0.
ADDRESS J08 M0.
CITY E I TRUNK PERMIT NO.
STA
UW TY
REGIBTRATIOM M0. tg- CONTY ROAD PERMIT NO.
LEGAL STATEINOROAOHMENT
DESCRIPTION LOT N0. PERMIT NO.
BLOCK TRACT INDUSTRIAL
WASTE APPROVAL
81Zfi OF LOT 0.OF BLDGIS
NOW ON LOT
OHARGEB
USE OF
BUILDINGS OONNEOTION CHARGE FEE
NO. DESCRIPT'IUN OF WO K FEE
HOUSE SEWER OONNECTINO TO REIMBURSEMENT FEE
PUBLIO SEWER 3_" RECEIPT NO. DATE BY
PRIVATE DISPOSAL SYSTEM O I./0 b
CONNEOT ADbifION BLDC 013 EXCEPTION RECORDED
WORK TO HOUSE SEWER_ L"
ALTEA 6h REPAili EXIVINGN0. DATE BY
SEWER OR DISPOSAL SYSTEM L"
DISOONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1.08 CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT R
PITS NRAINFI
D OR DELD 2-00 STATION DEPTH
CD
SPECIAL CONDITIONS ONLY 2.OS D MANHOLE REFERENCE
UPPER LOWER
TYPE OF CONNECTION LENGTH FROM
OWNERS PERMIT $ F Op Y. CURB P.L M.L TO P.L
AUTHORIZATION TOTAL FEE O
1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
OONTRAOTOR TO CONNECT THE ABOVE DISOBIBED EXISTINGAPPROVALS INGPEOTO BSIGNATUBE DATE
DWELLING TO THE PUBUD SEWER
SIGNED THIS DAY OF 19— NEW HOUSE BEEN t /
OWNER 00 CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
8EPT10 TANK.SEEP.PITS)
ADDRESS - ARD OR 0RAIMFIE
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLI- OESBPOOL RYWELL 0
CATION AND STATE THAT THE ABOVE 18 CORRECT AND AGREE
TO OOMPLY WITH ALL OOUNTY ORDINANCES AND STATE LAWS ALT1rR REPAIfl SEWER OR
REGULATING PLUMBING AND SEWERS. BEWA ED 18POf!►L SYSTEM
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED DISCONNECT PLULAND
MND/OR LICENSED AS REQUIRED Ely"
LOS ANGELES OOUNTY ABANDON ROUGE SEWER
AMD STATE OF CAUFORNI OR T • IAM THE L OW -
ER OF THE A90VE D D ENTIAL P A ❑
BEEP.PITmE] C[SGPOOLi
} SIGNATURH
OF PERNIITT
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