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DEPARTMENT OF COUNTY ENGINEER SEWER-SEWAGE DISPOSAL 1
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER BUILDING
ADDRESS �.�.�ds� t Ax
FOR APPLICANT TO F1.1-6 IN LOCALITY
BUILDING � � NEAREST
ADDRESS Ssi' //j,/jf CROSS ST.
LOCALITY DISTRICT NO. SERIAL NO. PERMIT NO.
NEAREST A v 7�r�(J J
CROSS ST. p ,���� �/
�R,ECEIVED BY Ready for Inspection DATEPISSUEsDy,�
OWNER c, { 'L ! // /�d7. �� fT�� "►
AD RESS ✓/�l/ T,� I'` �rUSE ZONE OCCUPANCY
MAIL ' BK MAP PG p.
CITY ��� TEL.NO.
i
CONTRACTOR CO.IMP.NO. 4` 9
ADDRESS JOB NO.
CITY TEL. b TRUNK PERMIT;,NO.
STATE
REGISTRATION NO. a COUNTY ROAD PERMIT N0.
LEGAL ea STATE ENCROACHMENT
DESCRIPTION LOT NO. PERMIT NO.
.1:
BLOCK TRACT � INDUSTRIAL
TE APPROVAL
SIZE OF LOT �b + l.9 NOW ON LOTNO.6F S CHARGES
USE OF f� �� /��
BUILDINGS isrs CONNECTION CHARG E
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO REIMBURSEMENT FEE
If PUBLIC SEWER @ $ 3.50 � RECEIPT N0. DA BY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.OR EXCEPTION RECORDED
WORK TO HOUSE SEWER 1.00 O
ALTER OR REPAIR EXISTING NO. I DATE I BY
_SEWER OR DISPOSAL SYSTEM 1.00
,DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1.00 CONNECTION DATA
SEP IC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 2.00 STATION ��C3 DEPTH lj
CESSPOOL—DRYW ELL
SPECIAL CONDITIONS ONLY 2.00 �/ M17ANHOLEREFERENCE
/G Al� �_'/ I LOWE
TYPE OF CONNECTION LENGTH FROMCw
OWNERS PERMIT $ 1 00 Y. CURB P.L. M.L.TO P.L.
AUTHORIZATION I TOTAL FEE
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER
SIGNED THIS_---•--•-•-•----DAY OF.......-...........--...._.._---.19.._... NEW HOUSE SEWER L/i l�i•� D
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT..........._......_. BUILDING OR WORK
SEPTIC TANK,SEEP.PIT(S)
ADDRESS----.--••---------...-•----------•------_--------------------------------------..-._--- AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI- CESSPOOL❑ DRYWELL
CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER,REPAIR,SEWER OR
REGULATING PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED DISCONNECT PLUG AND
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOUSE SEWER
AND STATE OF CALIFORNIA OR THAT 1 AM THE LEGAL OWN-
ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS�
ITTEE- _ _ _•Q�� _��d Q^� SEE �
�P.PIT(S) ,(eCE�SSPOfOLS�f�
SIGNATUIGNATU RE
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