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CE80810-63 76A6420 APPLICATION FOR PERMIT
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COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County Engineer ADDRESS
110
WILLIAM A. JENSEN, Supt of Building
LOCALITY
NEAREST �
FOR APPLICANT TO FILL IN CROSS ST, `
LEGAL --- --- – -�
DESCRIPTION LOT NO. OWNER
MAIL
BLOCK TRACT •� ADDRESS
N OF BLDGS.
SIZE OF LOT NOW ON LOT CITY T.L. N
USE OF DISTRICT NO. GROUP MAP PROCESSED BY
BUILDINGS BK
CONTRACTOR �� . Cle
ADDRESS
CONN CTION DATA
STATION DEPTH
CITY `
�J TATE MANHOLE REFERENCE
REGISTRATION NO. �{/ COUNTY LOWER
NO. DESCRIPTION OF ORK FEE TYPE OF CONNECTIONLENGTH FRO
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L.
PUBLIC SEWER $5.00 P.C.NO. O
SEPTIC TANK,SEEPAGE PIT OR JOB NO.
PITS AND/OR DRAINFIELD @ E10.00 CO.IMP.NO. V
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. CC
PRIVATE DISPOSAL SYSTEM @ $3.00 0
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE
WORK TO HOUSE SEWER $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD CL
EXTN.,CESSPOOL,DRYWELL,MANHOLE 45.00 O.
HWY. OR ST.WIDENING H
ALTER.REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM E3.00 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
OWNER'S PERMIT $ z 00
CONNECTION CHARGE FEE CHARGES
AUTHORIZATION TOTAL FEE
-I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN AMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS // DAY OF 1
OWNER AGE—Z `C� '/}.1 �S A/I A,, / ` ) NEW HOUSE SEWER
OWNERS AGENT �I' / CONNECT ADDITIONAL
��j� � - 1tiL. BUILDING OR WORK
ADORES {{�� (((��� SEPTIC TANK,SEEP,PIT(5)
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION 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 [IDRYW ELL ❑
I HEREBY CERTIFY THAT I 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
RESIDE IN, THE ABOVE DESCRIB D RESIDENTIAL P PE RTY. ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMITTEE ❑
SEEP.PIT(S) ❑ CESSPOOLS
VALIDATION ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
CK. / M.0 CASH
l
DEPA$'UNT OF COUNTY ENS SEWER�SEWAGE DISPOSAL 1
-DIV &ON OF BUILDING AND SAFETY PERMIT APPLICATION
OOUNTY OF L08 ANGELM
WILLIAM J. FOX, CouNTY EHOINEER BUILDING
ADDRESS
BUILDING TR APPUCANT TO RLL IN LOCALITY c
ADDRESS VCUG C ��E� E� OROBS �L a1.�
LOCALITY / DISTBIOT M0. S.KB1AL M0. PERMIT NO.
NEAREST A a or S
cRoeS ar
[ EIVE BY Boadr for Imsp=Uou DyrE I SVED
OWNER % '
MAIL �� U8fi ME OCCUPANCY MAP
ADDRESS _� —
BK PC
CITY TELNO.
CONTRACTOR POTRERCONTRAOTOR pl 11AAANG �•y+r,� D0.IMP.NO.
ADDRESS 54e N. DARLINGMN ST,.AT.7.70
JOB.M0.
CALIF.
CITY TEL-NO. TRUNK PERMIT NO.
REGISTRATION NOREGISTRATION�COUNTY COAD PERMIT NO.
LERALSTATE ENCROACHMENT
DESCRIPTION LOT M0. PERMIT NO.
BLOCK TRACT INDUSTRIAL
WASTE APPROVAL
SIZE OF LOT M0.OF BLDGS.
NOW DM LOT CHARGES
USE OF
BUILDINGS OONMEOTION CHARGE FE[
NO. DESCRIPTION OF WORK FEE REIMBURSEMENT FEE
{ i GON M
PUBLIO SEWER 0 7.60 Mfi0[IPT M0. DATE BY
HOUSE—BEWER M NG TO
PRIVATE DISPOSAL SYSTEM Im
N Eof-AbbITIO�IA -BLO OR EXCEPTION RECORDED
WORK TO HOUSE SEWER IA{ O
AL ER OR REPAIR EXI MQ NO, DATE BY
SEWER OR DISPOSAL SYSTEM I-00
131600NNEef AND ABAN OY EB
AND/OR DISPOSAL SYSTEM 1.110 CONNECTION DATA
SEP110 TANK,{CCPX6E P OB
PITS AND OR DRAINFIELD lie STATION DEPTH
6ERPOOL--DkYWE_LL
SPE04AL CONDITIONS ONLY S-M MANHOLE REFERENCE
UPPER LOWER
TYPE OF CONNECTION LENGTH FROM
OWNERS PERMIT $ I I 00 Y, CURB P.L M.L TO P.L.
AUTHORIZATION TOTAL FEE 1 21,00
1 HAVE THIS DATE DONTRAOTED WITH THE HEREIN NAMED
OONTRAOTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INBrEGTO WGMATUR[ DATE
DWELLING TO THE PUBLIG SEWER
SIGNED THIS DAY OF 19_ NEW HOUSE OMER ` l "� 7 3- 3'
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
SEPTIO TANK,BEEP.PIT(i)
ADDRESS AND OR DRA NFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLJ- CESSPOOL I] DMYWELL
CATIONAMD STATE THAT THE ABOVE 19 CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER REPAIR SEWER OR
REGULATING PLUMBING AND BEWERL SEWA�E 0I{PO�AL SYSTEM
1 HEREBY CERTIFY THAT 1 AM PROPERLY QEOI{TEMED DISCONNECT PLUG AND
AMD/OR LICENSED AS REQUIRED BY LOB ANGELES COUNTY ABANDON HOUSE SEWER
AND STATE OF CAJ.KORNIA OR THAT I AN THE LEGAL OWN-
ER OF THEA 3RIBED 81DENTIAL PROPERTY. ANKS SIGNATURE ❑
SEEP.PIT({)� CESSPOOLS l
OF PERMITTE
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