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75A542D APPLICATION FOR PERMIT
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COUNTY OF LOS ANGELES SEINER-SEWAGE DISPOSAL
DtPARTMENT OF COUNTY ENGINM
BUILDING AND SAFETY DIVISION BUILDING Q
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LOCALITY
NEAREST F FOR APPLICANT TO FILL IN `ROES ST. _
DESCRIPTION LOT NO. jr f /\/ /f MAIL
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[LOCK TRACT /G!/ ADDRESS
NO, OF ■LOOS.
SIZE OF LOT NOW ON LOT CITY C O•
USE OF DISTRICT NO. GROUP MAP PRbCESSED My
BUILDINGS
S eK ro
CONTRACTOR _. D�
ADDRESS CONNECTION DATA
STATION DEPTH
CITY TEL. NO.
STATS U P
RKOISTRAT10N NO. COUNTS' MANHOLE REFIRING[
NO. DESCRIPTION OF WORK FIE TYPE OF CONNECTION LENGTH FROM
S �O
HODS[SW[71 CONNECTING TO Y. CURB P. M.L.TO P.L.
PUBLIC SEWER t [5.00 U P,C,NO.
B DTIC TANK,S O[PTT OR MP.MP.NO. JOB NO. H
PITT AHD/OR DRAINFI[LD 0 •10.00
HOUSE SEWER CONNECTING TO TRUNK PERMIT O. ROAD PLRM(T NO.
PRI VATI DISPOSAL SYSTEM 113.00 im
CONNECT ADDITIONAL■ G.OR AFFIDAVIT fATT WIOLLIR RECORD.COR .INSTR.NO. DATE W
WORK TO HOUSE■EWER E2.00
OVERFLOW SEEPAGE PIT,DRAINFI[LD
EXTN.,CEEBPOOL.,DRYWRLMANHOLE 0 15.00
ALTER.RFP I ORA DO HWY.OR BT.WIDQIING N
SEWER OR DISPOSAL @Y/TEM 41 E3.00 I STATE UICROACHMOlT Z
PERMIT NO.
INDUSTRIAL
� WAST[APPROVAL
O nff: DPEnmIT
2 00 CHARGES
AUTHORIZATION TOTAL FEF a CONNECTION CHARGE FEE
.1 HAVE AT THISDATE A CONTRACT WITH THE HEREIN NAMED COM- REI E
RMSURS[M[NT FE
TACTOR TO CONNECT THE ABE S
OVDECRIBLD pSIiTINO DWELLING
TO THE PUBLIC SEWER. APPROVALS DAT[ INSPFCTO .S SIGNATURE
SIGNED THIS DAY OF
OWNER OR NEW HOUSE SKW[R �I
OWNERS AGENT CONNECT ADDITIONAL
BU ILD I NO OR WORK
ADDRESS SEPTIC TANK.SEEP,Fit(s)
I HERBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STAT[ THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
FLUME SHG AND Ill.[RS. CESSPOOL El DRYW[LL ❑
I HERESY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER.REPAIR,SEWER OR
LICENSED AS REQUIRED ■Y LOS ANGLES COUNTY AND STAT[ OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT 1 AM TH[ LEGAL OWNER OF. AND INNOTO. ISCONN[CT FLUO AND
RUED[ IN, THE ABOVEZFAFCDRESIDENTIAL P ABANDON NOUS[BEW RR
SIONATURE BACKFILL BEP�GTANKS ❑
OF PERMITTEE SEEP.PIT(S) CESSPOOLS
VALIDATION ROBERT A. WOOD
C SUPERVISING MECHANICAL ENGINEER
CK. M.O. CA1H
LN-104 8 8 2:S SEP 22 1 0 4 7.00~
A1o�a
7aAe4842D APPLICATION FOR PERMI
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I.hb- ,COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
D$PAR�ME OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION �oonus fA0161
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V►III.IAI[ A. IM s>tr E Of STC G �7rt
LOCA L R'fY
N F1 R[ST
FOR ANT TO IN IcRO/' ■T'
DLOCRIPTION OWNER
BLOCK TRACT '►� ADDRU/ f ! /C//rc/ti�
of eLDaf.
SIZE OF LOT NOW ON LOT CfTY L. NO. ap
Uf[ OF Di• CT NO. OOUF�RMAP BY
■UILDINGS /��
■K
TR ]Q�/' ro
CONACTOR. GI Y/ O / C.' , o V
ADDRESS /, ,C� /VY�d.fi �/ �� CONNECTION DATA
CITY /f� TIL. NO. 4
'^4
5i � /RATION D[PTK
U PIP"
L` OUNTY MANHdL F MCE L.9w R
REOISTRATRON NO. V
NO. DESCRIPTION OF WORK FEE TYPE OF CoION GTH FROM
EER
HOU■[SWCONNLCTING TO Y. CUR■ .L M.L.
PUBLIC SEWLR •e.00 P.G O.
■ PTIC ANK,■ FAO[FI O CO,IMF.NO. NO.
FIT/AND/OR DRAINFILLD $IO.Ob
HOU BF■[WLR CONNECTING TO TRUNK P"MIT NO. ROAD PER O.
PRIVATI Dlfro■AL SYSTEM 43.00 OL
CONN[ ADDITIONAL■ .O R
AFFIDAVIT ■AIR[ w[ Irt RECORD.INSTR.NO. pATZ O
WORK TO HOU■[SEWER 41.00
OVERFLOW SEEPAGE FIT.DRAI NF1 RD
IEXTN.,C61SP0 OL,D NHOLE 43.00 N
D HWY-OR R.WI D INO
If POSA M - 1.00 fTATE[NCR HM NT
PERMIT NO.
INDUSTRI
W A1TI
C HARD<D
OwNER'S PEBMT 1612 00
AOTHORMATION TOTAL FEF. G Q CONNECTION CHARGE F[[
'1 HAVE AT THIS DAT[ A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSIMrwr FII
TRACTOR TO CONNECT THL ASOVS DLSCRIS[D RIFTING DW[ LINO
TO TH[ PUBLIC SEWER. APPROVAL DAT[ IN■PECTOR'S SIGNATURE
SIGNED THIS DAY OF IG_
OWN[n OR NL [
w HOUSE/ WLR
OWNERS AGENT CONNECT ADDITIONAL
BUILDING OR WORK
ADDRLS ■EPTIC TANK,■ELP,PIT(S)
I H[RO
[■Y ACKNWlLDGE THAT I HAV[ RLAb THIS ARLICATION AND/OR DRAINFI[LD
AND STAT[ THAT THLABOVE 15 CORRECT AND AORU TO COMPLY
WITH ALL COUNTY ORDINANCES AND STAT[ LAWS R[GUL,ATNG
PLU MS ING AND SEWLRI. CIS4PO0L ❑ DRYwELL ❑
I HRR[■Y CERTIFY THAT I AM PROPERLY ROISTERED AND/OR ALTCR,REPAIR,SEWBR OR
LIC[NBLD AS ROUIRED ■Y LOS ANGL.IS COUNTY AND STAT[ OF ■[WAG[DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTIND TO DISCONNECT PLUG AND
RAID[ IN, TH[ ABO CRI■FD R L PROPERTY. ABANDON HOUSE f[W LR
S IO NATUR BACKFILL SKP C TANKS ❑
OF PLRMITTLI FLIP,PITS) �J CWPOOLS
ATION ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
CK. M.O. CASH
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