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S&E6-665 3-3!; A®®L I C A T I ON' ® qPERMIT ERpIT
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DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL'
Department of County Engineer
County of Los Angeles BUILDING �� cJ ,g /��� '� A
WM.J. FOX, COUNTY ENGINEER ADDRESS 7 J'�7 ° EF
/VA
D. GRIFFIN, SuwT of BUILDING LOCALITY.
NEAREST
FOR APPLICANT TO FILL IN CROSS ST, '
DESCRIPTION LOT NO. DSO• OWNER 6 UTl /v
-ply TRACT / MAIL '
ADDRESS
NO. OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO. '
USE OF
BUILDINGS ,A DISTRICT NO, GROUP MAP
CONTRACTOR �F/��n A/ /C � V C/< BK PG
YYY l
ADDRESS`27 r A j 9A,N 7'A A ti//-/-A CONNECTION DATA
CITY C f TEL. NO-A T72 7 4p 7 9 STATION t L � � DEPTHSTATE �
REGISTRATION N0. r / ❑ COUNTY MANHOLE REFERENCE �� UPPER
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO moi_ TYPE ECTION LENGTH FROM
Tf� CURB M.L. TO P.L.
PUBLIC SEWER Q $ 3.50
HOUSE SEWER CONNECTING TO '
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG. OR P. C. N0.
WORK TO HOUSE SEWER 1.00 CO. IMP. NO. JOB N0.
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM 1.00 TRUNK PERMIT NO. ROAD PERMIT NO.
DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT
AND/OR DISPOSAL SYSTEM 1. 0 PERMIT NO.
SEPTIC TANK, SEEPAGE PIT OR
PITS AND/OR DRAINFIELD .00 INDUSTRIAL
CESSPOOL-DRYWELL WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2.00 CHARGES
PERMIT CONNECTION CHARGE FEE
OWNER'S S 1 ' 00
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
TRACTORHAVE TTOS CONNECTDATE ONTRTHEAABODVEWDESCR BED EXISTINGITH THE HEREIN A DWELLING APPROVALS D �DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER ,^ -
SIGNED THIS 6 DAY OF P �� Ig ,' / NEW HOUSE SEWER S m 'd-o �
OWNER OR --""'yy CONNECT ADDITIONAL V y
OWNERS AGENT ��<< F��'�' f��-'+'�' .BUILDING OR WORK
• ° SEPTIC TANK,SEEP, PIT(S)
ADDRESS ,'AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL C1 -
AND 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 I 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 r- -
a. SEEP. PITS) ❑ CESSPOOLS,
❑
SIGNATURE Fi'
OF PERMITTEE.!1-�.=Av'?� 1 i•/, a tt
WILLIAM J.'FOX,COUNTY ENGINEER VALIDATION R.A.WOOD, CHIEF PLBG. INSPECTOR
t�. .2 7 s 6 .sem 30 4 4.50 M