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DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE D B S PO SA L
Department of County Engineer
County.of Los Angeles BUILDING
WM.J. FOX, COUNTY ENGINEER ADDRESS n
CASSATT D. GRIFFIN, SUPT OF BUILDING LOCALITY F
FOR APPLICANT TO FILL IN NEAREST
CROSS ST. •�Lrq.
LEGAL 4 64-7
DESCRIPTION LOT NO. nk OWNER
tl
BLOCK TRACT /`� MAIL
S _ADDRESS -
NO. OF BLDGS.
SIZE OF LOT NOW ON.LOT CITY "TEL.
USE OF / , 939HPIRM =I&
BUILDINGS ,� 'S.•a.�' - 'DISTRICT NO. GROUP MAPS
K PG
CONTRACTOR 5
ADDRESS CONNECTION DATA Y
CITY '•'TEL. NO. STATION 7'--�} DEPTH �-
�y x STATE t3 MANHOLE REFERENCE
REGISTRATION NO. �• � "� / [ICOUNTY �-�� �a �/' UPPER I^W R
TYPE OF CONNECTION LENGTH FROM j1 /
NO. DESCRIPTION OF WORK FEE CURB M.L.TO P.L. C/
HOUSE SEWER CONNECTING TO
PUBLIC SEWER Qi $ 3.50
HOUSE SEWER CONNECTING TO
_ PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG. OR CO. IMP. NO. / JOB. NO.
WORK TO HOUSE SEWER 1.00 -f
ALTER OR REPAIRNG
--SEWER OR DISPOSALL SYSTEM 1.00 TRUNK PERMIT N0. ROAD PERMIT NO..
DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT
AND/OR DISPOSAL SYSTEM 1.00 PERMIT NO.
SEPTIC TANK, SEEPAGE PIT OR -
PITS AND/OR DRAINFIELD 2.00 INDUSTRIAL
CESSPOOL- DRYWELL WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2.00 CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT $ 1 00
AUTHORIZATION I TOTAL FEE REIMBURSEMENT FEE
TRACTORHAVE T TOS CONNECT THE DATE ABOVECTED WDESCR BED EXISTINGITH THE HEREIN AMED DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER
SIGNED THIS DAYOFG/O. "Ara c 19 NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT///(((��� HCl/_A�. V /GSC. BUILDING OR WORK
ADDRESS J��k�, SEPTIC TANK, SEEP, PIT(S)
J� AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION CESSPOOL[3DRYWELL❑
AND STATE-THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY. ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. ALTER, REPAIR, SEWER OR
SEWAGE DISPOSAL SYSTEM
IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF HE ABOVE
DESCRIBED RESIDENTIAL PR ERTY. BACKFILL SEPTIC TANKS❑
SEEP: PIT(S) ❑ CESSPOOLS�IEJ -
SIGNATURE
OF PERMITTEE
WILLIAM J. FOX, COUNtY-frIlGINEER V92bATION
.. � 8 � �: AUG18 4 4.50
;BY � B
DEPUTY DEPUTY
BY BY
®" DEPUTY DEPUTY