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76A6421APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION4NEAREST
ING
JOHN A. LAMBIE. County EngineerSS
WILLIAM A. JENSEN. Sup't of Building
ITY
., ,. ., .. ... .... .:..... ..
FOR APPLICANT TO FILL IN BT.
LEGAL
DESCRIPTION LOT NO. OWNER S'
MAIL
BLOCK TRACT ADDRESS
NO. OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
UUSE OFIDISTRICT NO. GROUP MAP PROCESSED BY
BILDNGS
BK PG
CONTRACTOR
ADDRESS p CONNECTION DATA
CITY TEL.I'.. . , STATION DEPTH
,t ^ ❑ STATE MANHOLE REFERENCE UPPER
REGISTRATION NO, ♦/ h 0 O El COUNTY LOWER
NO. DESCRIPTION OF WORK FEE TYPE O CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y P.L. M.L.TO P.L. }
PUBLIC SEWER @ 55.00
SEPTIC TANK,SEEPAGE PIT OR NO. a
PITS AND/OR DRAINFIELD @ 510.00 CO.IMP. NO. JOB NO. O
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. V
PRIVATE DISPOSAL SYSTEM @ S3.00 w
CONNECT ADDITIONAL BLDG.OR gFFIDAVIT INANE" EASEMENT RECORD,INSTR.NO, O
WORK TO HOUSE SEWER @ S3.00 I--
OVERFLOW SEEPAGE PIT.DRAINFIELD
EXTN..CESSPOOL,DRYWELL,MANHOLE @ $5.00 IL
HWY.OR ST.WIDENING
ALTER. N HOUSE �� h
SEWER OA.a3bAB6A•1-•6Y62EM @ S3.DO STATE ENCROACHMENT z
PERMIT NO.
INDUSTRIAL
WASTE A OVAL
OWNER'S PERMIT s 2 00
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE
['IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19_ -
OWNER OR NEW HOUSE SEWER
OWNERS AGENT
CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS SEPTIC TANK.SEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ❑
I. PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL
R / t
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR //�/�/��(p
LICENSED AS REOUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM /' S
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND f
j RESIDE IN,IDE IN, TH�VE DESCRIBED R SIDEN TIA PR OPERTYDESCRIBED R SIDEN TIA PROPERTY. ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
} OF PERMITTEE SEEP,PIT'S) ❑ CESSPOOLS ❑
VALIDATION ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
CK..
11.0. CASH
Lf�il�o 5 0 0 3. OCT 1_ 9 1 0 D 5.00-
-i' DEPARTMENT OF COUNTY ENGINEER SgWER-SEWAGE DISPOSAL
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ®NGEjY.F;S
WILLIAM.J. FOX, COUNTY ENGiNEEn 1I BUILDING
ADDRE88
FOR APPLICA TO FILL.1 DcaLlTir /_ �
NG NEAREST,
FADDRESSBUILDiCROSS ST.CALIT DISTRICT N0. Rmcly.tor Inspeotion 33PERMITH0> c7� -46� S
ARES JOSS ST. /
DATE
,{ ISSUED BY =DATE.
OWNER
MAIL USE ZONE OCCUPANCY BK101�P PO
ADDRES
CITY /ATEL.NO. �� tS
CONTRACTO ���, �� � �� l�� - CO.IMP.NO. / �5—�
ADDRESS r JOB NO.
CITY�� TEL.NO4��.�j TRUNK PERMIT NO.
TATE
REGISTRATION NO. .�p� B COUNTY ROAD PERMIT NO. P—?-c—3
LEGAL STATE ENCROACHMENT
DESCRIPTION LOT NO. 34f PERMIT NO. C
BLOCK TRACT �5 INDUSTRIAL
TNO.OF 6LOGS.
gga� WASTE APPROVAL A
SIZE OF LOTo���i/ NOW ON,LOT ✓ ARG ES
BUILDINGS DINGS „%f�yJ�� �jNP_SJ/1U.��Nro H' CONNECTION COF HARGE-FEE'
NO. DESCRIPTION OF WORK FEE y \ /
HOUSE SEWER CONNECTING TO REIMBURSEMENT FEE �(
PUBLIC SEWER Q f 3.50 _ �� RECEIPT NO. AT BY
HOUSE SEWER CONNECTING TO 1 I '
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLOG.OR EXCEPTION RECOR D
WORK TO HOUSE-SEWER- - 1.00 Q"Q
ALTER OR REPAIR EXISTING NU. I� DATE I BY
SEWER OR DISPOSAL SYSTEM 1.00 /�I1
DISCONNECT AND ABANDON SEWER
_ AND/OR DISPOSAL SYSTEM 1.00 CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR �JQ� 0
PITS AND/OR DRAINFIELD 2.00 STATION �" / U DEPTH
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 2.00 _ ^ 4 ,r MANUHOLE PPER REFERENCE
oC TYPE OF CONNECTION LENGTH FROM h
OWNERS PERMIT s 00 CURB a - M.L.TO P.L. oC
AUTHORIZATION TOTAL FEE
1 HAVE THIS DATE CONTRACTED WITH THE HER N NAMED ,.
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR'S SIGNATURE - DATE
DWELLING TO THE PUBLIC SEWER
SIGNED THIS Y lJ 1 __ NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT_._'_ I ' BUILDING OR WORK
ADDRESS.._.�._� SEPTIC TANK,SEEP.PITS)
- ••�-- ••- - ----• =•-•-•-- � AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI. CESSPOOL E DRYWELL
CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS '.ALTER,REPAIR,SEWER OR . .
LAND/OR
NG PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
BY CERTIFY THAT I AM PROPERLY REGISTERED DISCONNECT PLUG aND
ICENSED A3 REQUIRED BY LOS ANGELES COUNTY ABANDON HOUSE SEWER
E OF CALIFORNIA OR THAT I AM THE LEGAL OWN-
E ABOVE DESCRIBE RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS
ESEEP.PIT(S)E] CESSPOOLS TTEE =�..- — -- -- ---.:.:. ,
76A642D S&E 663 4/54