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DEPARTMENT OF COUNTY ENGINEER � SEWER-SEWAGE DISPOSAL
DIVISION OF BUILDING AND SAFETY MIT APPLICATION
COUNTY OF LOS ANGELES gU1LDING
PERMIT
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WILLIAM J. FOX, COUNTY ENGINEER I ADDRESS 90 T 3_/`7 Z 14/'00,0
"`>=FOR APPLICANT TO FIL "1N LOCALITY jFjy�`�c C/Ty
BUILDING NEAREST C
:,AD;DRESS CROSS ST.
�,. DISTRICT NO. SERIAL NO. PERMIT NO.
LOCALITY 0% � Gti 9 •. c
,NEAREST A S
CROSS SIA q_./
D � RECEIVED BY Ready for Inspection DATE ISSUED ;
OWNEF
-ADDRESIC; USEZONE OCCUPANCY BK MAP PG
CITY TEL.NO.
A r I A=- 79
n�n�� �. 1.70
CONTRACTOR V' jCO.IMP.NO. f ®�
ADDRESS e2 �,,2.,yJ / r7 / JOB N0.
"CITY �- TEL.NO.L Q CPGf G W • TRUNK PERMIT NO.
,:RkGISTRATION NO. ' 3 a A? g COUNTY ROAD PERMIT NO. O
;.DESCRIPTION LOT NO. /� STATE ENCROACHMENT
- PERMIT N0.
BLOCK' ;- :, TRACT �� '� INDUTRIAL TE APPROVAL
SIZErOF COT�CQ_�_���� �® NOW ON LOTS CHARGES .tet
USE OF
BUILDINGS �t 7'i7�
CONN TION CHARGE FEE
NO. DESCRIPTION OF WORK FEE I
REIMBURSE T FEE
HOUSE SEWER CONNECTING TO rr
PUBLICSEWER @ $ 3.50 3 J� RECEIPT-NO. DATE
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.OR CEPTION ftQ,0RDED
WORK TO HOUSE SEWER 1.00
ALTER OR REPAIR EXISTING NO- I DATE BY
_SEWER OR DISPOSAL SYSTEM 1.00
e 'DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1.00 CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR p
PITS AND/OR DRAINFIELD 2.00 STATION ���� -DEPTH 1p
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 2.00 A� MANUPPER REFERENCE LIR
(Q i
TYPE OF CONNECTION LENGTH FROM m,
OWNERS PERMIT $ 1 00, x- CURB- P.r. M.L.TO P.L. CJS
AUTHORIZATION I TOTAL FEES
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INS PE TOR'SSIGNATURE DATE
DWELLING TO THE PUBLIC SEWER
SIGNED HIS..________________:DAY OF_---___J. ..__f..7..19��1 NEW HOUSE SEWER 11Z�) �+
OWNER OR r ✓L,., . t7. CONNECT ADDITIONAL
OWNERS.• AGENTc� !-..:._. 0/ �y7-A .. ....... BUILDING OR WORK
SEPTIC TANK,SEEP.PIT(S)
ADDRESS----------------------------------------------.-.............................................: AND/ORDRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI. CESSPOOL E3 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
SEEP.PIT(S)0 CESSPOOLV001
SIGNATURE
OF PERMITTEE - _l_-`-...__... •- - -
76A642A 663 7/53