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`�'..�'o "AP63 3-5s PLICATION FOR PERMIT'8.E.eDMSION OF BUMDING AND SAFETY SEWER—SEWAGE DISPOSAL
Department of County Engineer
County of Los Angeles BUILDING
WM.J. FOX, COUNTY ENGINEER ADDRESS
CASSATT D. GRIFFIN, SUPT OF BUILDING LOCALIT
NEAREST
FOR APPLICANT TO FILL IN CROSS ST. ,
LEGAL
DESCRIPTION LOT NO. OWNER _
BLOCK TRACT _ MAIL
AA ADDRESS `✓vva..ci
SIZE OF LOT y NO. OF BLDG
-
NOVON LOT CITY TEL. N0.
USE OF
BUILDINGS DISTRICT NO. GROUP 9MAP
CONTRACTOR AK
t
Al— ,-2--
ADDRESS CdNNECTION DATA
CITY EL. NO. Z2 off STATION op,+� 6� DEPTH or
❑ STATE 'MANHOLE REFERENCE 6- S p, UPPER
REGISTRATION NO. ❑ COUNTY &b4AOO
NO. DESCRIPTION OF WORK FEE
TYPE OF CONNECTIq L.
LENGTH P.L.
HOUSE SEWER CONNECTING TO Y. CURB �� P.
L. M.L. TO P.L.
PUBLIC SEWER Q $ 3.50
HOUSE SEWER CONNECTING TO
PRIVATE,DISPOSAL SYSTEM 1.00 _
CONNECT ADDITIONAL BLDG. OR �¢ P. C NO.
WORK TO HOUSE SEWER 1.00 CO. IMP. NO. , j� JOB NO.
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM 1.00 TRUNK PERMIT NO. ROAD PERMIT NO.
DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT
_ AND/OR DISPOSAL SYSTEM 1.00 PERMIT NO,
SEPTIC TANK, SEEPAGE PIT OR
ITS AND/OR DRAINFIELD .00 INDUSTRIAL
VAL
CESSPOOL- DRYWELL WASTE APPRO
SPECIAL CONDITIONS ONLY 2 00 CHARGES
OWNERS PERMIT 7 00 CONNECTION CHARGE FEE,s
AUTHORIZATION I TOTAL FEE �REIMBURSEMENT FEE
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCR ED EXISTING DWELLING APPROVALS DATE INSPECTORS SIGNATURE
TO THE PUBLICS _
SIGNED THIS AY OF..,/`nig NEW HOUSE SEWER Ot.
OWNER- OR ,✓ '�_-1/_1, � CONNECT'ADDITIONAL
OWNERS AG� 777///LLL"' BUILDING OR WORK
SEPTIC TANK, SEEP, PIT(S)
ADDRAND/OR DRAINFIELD
I HEREBY ACKNO T rtAVE REA THIS APPLICATION CESSPOOL❑ DRYWELL 171AND STATE THAT THE'ABOVE IS CORRECT AN AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. I SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND
CALIFORNIAOR THAT/ AM THE LEGAL OWNER OF THE ABOVE ABANDON HOUSE SEWER
DESCRIBED RESIDENT,1'A PROPERTY. BACKFILL SEPTIC TANKS❑
a SEEP. PIT(S) ❑ CESSPOOLS(11—
sic
11
SIGNATURE
OF PERMITTE
WILLIAM J.FOX.COUNTY ENGINEER V gATION R.A.WOOD, CHIEF PLEIG. INSPECTOR
��co 3 5 1 4 JUL 2 4 4 4.5 0 �'