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COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL.
DEPARTMENT OF COUNTY ENGINEER — —
BUILDING AND SAFETY DIVISION BUILDING j
ADDRESS
LOCALITY ( C,
NEAREST /
FOR APPLICANT TO FILL lid CROSS 5T. c-4 -l2 • �—
LEGAL
DESCRIPTION LOT NO. OWNER
MAIL l /
BLOCK TRACT / � Get*-_3 ADDRESS � � „3 �'�.' i ! � •
NO. OF DS.
BLG
SIZE OF LOTl� NOW ON LOT CITY /�: ��K TEL. NO.USF
�- - �/.J•
/,a r _ DISTRICT NO. GROUP MAP OCESSED BY
BUILDNGS �'`r j ,�/•<"_y BK p3
CONTRACTOR f i'I. iVi"7'i�7"i•�/ •/Y ,7 n�-' � �fi� � I � _ -
ADDRESS � -.s `.t... ►,;,• _ ,•.�_ CONNECTION DATA
y/�' 't STATION DEPTH
CITY fly .�l C TEL. NO. � �
STATE ��. LIC MANHOLE REFERENCE UPPER
LICENSE NO.. - 6� k CLASS LOWER
NO. .DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P:L. M.L.TO P.L.
PUBLIC SEWER @ $7.00 P.C.NO.
SEPTIC TANK,SEEPAGE PIT OR JOB NO. -
PITS AND/OR DRAINFIELD @ $10.00 CO.IMP. NO.
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. G.
PRIVATE DISPOSAL SYSTE @ S3.00 O
CONNECT ADDITIONAL B2. /'. AFFIDAVIT WAIVER '[n SEMS xi RECORD. INSTR.NO. DATE V
WORK TO HOUSE SEWER @ $3.00 L./
OVERFLOW SEEPAGE PIT.DRAINFIELD CC
EXTN..CESSPOOL.DRYWELL, @ $5.00 O
ALTER.REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING
SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHMENT W
MANHOLE @ $7.0 PERMIT NO. LL
INDUSTRIAL N
WASTE APPROVAL z
OWNER'S PERMIT S s 00 CHARGES
AUTHORIZATIONJ TOTAL FEE /i CONNECTION CHARGE FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEW APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OFf"�e`"''•' 19 �
OWNER ORNEW HOUSE SEWER
OWNERS AGENT
CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK /1'`� l AJrsOYN
/ 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 _
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL Cl
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR - ALTER,REPAIR,SEWER OR
LICENSEDAS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. ABANDON HOUSE SEWER
SIGNATURE �i BACKFILL SEPTIC TANKS ❑
OF PERMffTEE
SEEP.PIT(S) ElCESSPOOLS ❑
VALIDATION CK. M.O. CASH
4 b y t► ii
1 y OU
76A642D rA P P L I C gAB"•0tl I O 1!� "FO PERMIT
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DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Department of County Engineer
County Of LOS Ange10S BUILDINGRNO.
WM.J:FOX, COUNTY ENGINEERADDRESSCASSATT D. GRIFFIN°Sup�•r of BUILDING LOCALITTc4
FOR APPLICANT TO FILL IN NEARESTCROSS ST. galLEGALDESCRIPTION LOT N0. OWNERBLOCK TRACT - AIL
pDRESSNO. OF BLDGS.SIZE OF LOT NOW ON LOT CITY
USE OF
BUILDINGS DISTRICT NO. GROUP MAP PG
BK
CONTRACTOR
ADDRESS /�' .y. ✓ CONNECTION DATA
CITY A4Uw1_-1 vA4TEL. NO.69 S—I/12-1 STATION DEPTH
U( STATE -MANHOLE REFERENCE
REGISTRATION NO. . S3 ❑ COUNTY UPPER - 'LOWER-
- TYPE OF CONNECTION LENGTH FROM
NO. DESCRIPTION OF WORK FEE Y. 'CURB P.L. M.L.TO P.L.
HOUSE SEWER CONNECTING TO
PUBLIC SEWER Ccs -S 3.50 _
HOUSE SEWER CONNECTING TO -
PRIVATE DISPOSAL SYSTEM 1.00_
CONNECT ADDITIONAL BLDG. OR. CO. IMP. N0. JOB. N0. '
WORK TO HOUSE SEINER 1.00
/ ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL 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
OWNERS PERMIT 1 00
AUTHORIZATION TOTAL FEE o2 REIMBURSEMENT FEE
TRACTORHAVE T TOS CONNECT THEDATE ACTEABODVEWDESCR BED EXITH THE ISTINGNAMED
DWELL G APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER - -
SIGNED THIS DAY OF - 19- NEW HOUSE SEWER .
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
SEPTIC TANK, SEEP, PIT(S)
ACDRESS . AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL[3
AND STATE,THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY '
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER, REPAIR,SEWER OR
PLUMB AND SEWERS. .SEWAGE DISPOSAL SYSTEM
IHEREBY CERTIFY THAT I AM 'PROPERLY REGISTERED AND/OR '
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND
CALIFORNIA. OR THAT 1 AM THE LEGAL OWNER OF THE ABOVE $ABANDON HOUSE SEWER -,
DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS❑
SEEP.PITS) ElCESSPOOLS.❑
SIGNATURE 1'I�e - }+• �t �'.t� -
OF PERMITTEE Cd vvV qu✓° .-
WILLIAM J. FOX, COUNTY ENGINEER VALIDATION
is
"BY BY
DEPUTY - DEPUTY '
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DEPUTY
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