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DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE D 9 S POSH L
Department of County Engineer I
County of Los Angeles A��RESSG
WM.J. FOX, COUNTY ENGINEER
CASSATT D. GRIFFIN, SUPT OF BUILDING LOCALITY
FOR APPLICANT TO FILL IN NEAREST
CROSS ST.
LEGAL /
DESCRIPTION LOT NO. - 24 OWNER I
BLOCK TRACT MAIL
ADDRESS I6 a
SIZE OF LOT 10 ,s NOWOON LOTS CITY TEL. NO.4" 776
USE OF
BUILDINGS IJ. rr 1J ] DISTRICT-NO. GROUP MAP
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^ CONTRACTOR /„�'Y/ A/�
ADDRESS G - /JQ CONNECTION DATA ,•I //
CITY '- TEL. NO.A eJ e.0 `�4V c U` 0,41' STATION f.9, 3+/O.�.� DEPTH
❑ STATE .�/. 4 1564771 UPPERREFERENCE LOWER
REGISTRATION N0. (� ❑ COUNTY (O
TYPEO�.GQI3 NECTION LENGTH FROM On
NO. DESCRIPTION OF WORK FEE Y. CURB , P.L. M.L.TO P.L.
HOUSE SEWER CONNECTING TO 3 -
PUBLIC SEWER c) $ 3.50
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG. OR CO. IMP. N0. / Q JOB. NO.
WORK TO HOUSE SEWER 1.00
ALTER OR REPAIR EXISTING p�
SEWER OR DISPOSAL SYSTEM 1.00 TRUNK PERMIT NO. ROAD PERMIT NO./OY�ZD/
'DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT
•AND/OR DISPOSAL SYSTEM 1.00 PERMIT NO.
SEPTIC TANK, SEEPAGE PIT OR
PITS AND/OR DP,AINFIELD 2.00 INDUSTRIAL
CESSPOOL- DRYWELL WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2.00 CHARGES
CONNECTION CHARGE FEE
OvRMIS PERMIT b 1 00
AUTHORIZATION TOTAL FEE B O REIMBURSEMENT FEE
I HAVE DATECON-
TRACTORT TO CON ECTO THE ABOVEWDESCRIBED* ITH THEH EREIN EXISTINGAMED DWELLING APPROVALS DATE INSPECTORS SIGNATURE
TO THE PUBLIC:SER
SIGNED THIS DAY OF 19�. NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL '/ •"C�t.m'Y
OWNERS AGENT �� BUILDING OR WORK
ADDRESS AND/ORT DRAINFEIELDPIT(S)
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICAT ON CESSPOOL[3DRYWELL ElAND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE_LAWS REGULATING ALTER, REPAIR, SEWER OR
PLUMBING AND SEWERS. - SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND - -- - -
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE ABANDON HOUSE SEWER
DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS❑
/ P 6 SEEP. PIT(S) ❑ CESSPOOLS❑
SIGNATURE
OF PERMITTEE
WILLIAM J. FOX, COUNTY ENGINEER VALIDATION
��.t IN C 1 5 i L'1 i'AY / 4 4.50
B�
_B Y BY �y
DEPUTY t- // DEPUTY
BY BY Nom'/
.�0 DEPUTY ( DEPUTY