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CEBOB3-
76A6420 62 APPLICATION FOR PERMI
COUNTY OF LOS ANGELES SEWER-SEWAGE ISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County Engineer ADDRESS
WILLIAM A. JENSEN, Sup"t of Building
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL
DESCRIPTION LOT NO. OWNER
MAIL
BLOCK TRACT ADDRESS
NO. OF LDGS,
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE DI DISTRICT IN GROUP MAP O 54D BY
BUILDINGS qq
'�OA 0a _/ BK PG
CONTRACTOR Vl S _s l
I
ADDRESS CONNECTION DATA
EL. NO.
STATION ,C� �1 DEPTH /
CITY (` `J v
REGISTRATION NO. COUNTY MANHOLE REFERENCE // UPPER
Asomm
NO. DESCRIPTION-OF'WORIr PEEPE OF CONNECTION LEN TH FROM
HOUSE SEWER CONNECTING TO UV Y. CURB p.L. M.L.TO P.L.
PUBLIC SEWER @ $5.00
SEPTIC TANK,SEEPAGE PIT OR P.C.NO. O
PITS AND/OR DRAINFIELD @ $10.00 CO.IMP.NO. 3 JOB NO. / V
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT CLQ/ o
PRIVTA
E DISPOSAL SYSTEM @ $3.00 /
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT IWAIVER EASEMENT RECORD.INSTR.NO. DATE
WORK TO HOUSE SEWER @ $3.00
OVERFLOW SEEPAGE PIT.DRAINFIELD d.
EXTN..CESSPOOL.DRYWELL.MANHOLE@ $S,OO.I HWS, INC Z
ALTER,REPAIR OR ABANDON HOUSE - '
SEWER OR DISPOSAL SYSTEM $3.00 STATE ENCROAC
PERMIT NO. /
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT $ 2 00 CHARGES
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE U-a
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. APPROVALS DATE INSPECTOR'S SIG:!g
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT_ CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION SEPTIC TANK,SEEP,PITS)
AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL [:1 DRYWELL ❑
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR.SEWER OR
LICENSED AS REQUIRED BY LOS AN ES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT M TH EG OWN OeANNTE TO DISCONNECT PLUG AND
RESIDE IN, THE A ESC RESI ALTY ABANDON HOUSE SEWER
SIGNATURE
OF PERMtTTE _BACKFILL SEPTIC TANKS E] ❑
SEEP.PIT(S) ❑ CESSPOOLS
/Q/lJ VALIDATION ROBERT A. WOOD
(K'� M.O. CASH SUPERVISING MECHANICAL ENGINEER
c
zi
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78A"2133-61
aA"213enxo APPLICATION FOR PERMIT
COUNTY OF LOS ANG-0FS
SEWER—SEWAGE DISPOSAL
IWAETN[ENT OF COUNTY ENGINEER
BUILDING AND SAFETY DrfISION BUILDING
7 gN ow ADDNUDI• D
A.M
WILLIA, •A.. �l
LACALi
— X rJLREST -7 )t�'"ffm
R APMCANT TO Fnl IN emu
LEGAL IOWNER
DESCIIIPTIOR LOT NO.
BLACK TRACT wL
ADDRED!
BI DOS
am OF LOT ow OR LOT
USE OF DIfTl1CT R0. QROUP ST
BUILDINGS
�� >R M
COR7RA
ADDRESS COICKEc 1021 TA
CRIT TIL RO STATION DtPTH
sT RAIIHOLi tEF�LKIICK
RIGISTRATIOR no COUNTY
NO.
AgUfBC CORRICTIRG TO
P C T11��XI SZ
RAGE PIT OR T. TTFI OF CURD ORP L.l01 TOP.L.
MARTIN IN bRAIRF16LD
M,QOI/t1 StEPAG F AAIRlILLD
0 St COXR GTO P.C R0. O
�p1( g�App�770nA�, Co.IN
R0. JOB RO V
vol;TO HOUSE wdLDG. o 51.09 TRUNK MMMFT NO. DOAD PIMErT R0. OC
I ALTER. 0 HOUSE .00 STATE ENCROACHNIIT
PERMIT NO.
INDUSTRIAL
WAM APPROVALN
CHARGES Z
OWfon FEDUT $ 0.0 CONR1cn0■CHAlft Fill
AUTEOBMTION TOTAL F88 RIDNSURSEauT Fu
I HATE AT THIS DATI A COIITRACT fiTR THI IDR !11!® COR-
TRACTOR TO CORRECT THK ADM A KIIQTIIIf D�LUR4AMOVAM TI IN SPECTO •S SIORA
TO THE ]PUBLIC SKtEL
SIGNED THIS TRAY OF NEW NOUS=SBE!
OWNER OR CONNECT ADDITIONAL
OWNERS AGirN BUILDING 0!WORK
IC TANI SUMPIT(S)
R DRAINFIELD
1 HEREST ACKRo711DGI THAT C RATI AIDRAA[��1A1D THIS APTLICCqAnOR
WITHS]1LL RTT ORDIIIAIICtb L11D ST/►TED LA7<S lKGULATIIIf A TTi�tI,REPOOL PAIR.rE7ER 0!
FLURBIRG ARD SEWXRS.' :95E DISPOSAL ST
I HEREBT CKIMFT THAT I AN PROPERLT RIGISTIBID AAD/OR DISCORNICT PLUG AND
LICKmM AS REQUIRID BT LOS ANGELIS C AND STA71 OF ABANDON HOUSE SEVER
CALIFORNIA OB I A LEGAL OF ADOYE BACKFILLC TANKS
DESCRIBED RISID L S1Er PIT 1 POO
SIGNATURE
OF PQt 1
ATION ROBERT A. WOOD
Ci a.0. ora supon sINO Y[CliANIC"IQi0ma=
1,09 6 3 6 Qd VVIR 15 1 0 D 5.0 0