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DEPARTAIIENT OF COUNTY ENGINEER SEWER—SEWAGE DISPOSAL
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER + I BUILDING
ADDRESS
LOCALITY
FOR APP .4 BUILDINGFILL IN �" "��
NEAREST
ADDRESS / �GA(6.�1 CROSS ST / . e-!
DISTRICT NO, SERIAL NO. PERMIT NO
NEAREST, A
CROSS ST.
z RECEIVED BY Ready for inspection D TE�ISSUED
OWNER 1143S-L1
MAIL /O �J� l USEZQNE OCCUPANCY BK'�A PG
ADDRESS G�"�^' �� ;r'�"" -
CITY p .�TELAO. 19-1 � �$
CONTRACTOR /� . �.; zo..1MR.-N9 ef 0
P 7
ADDRESS-,,l!- 441 �� � �� JOB NO (�
CITY e_ _ TEL NO. , TRUNK PERMIT NO
REGISTRATION NO ! G �� cm
- STaCQ13NT-y* ROAD PERMIT NO
LEGAL o
DESCRIPTION LOT NO STATE ENCROACHMENT
7 PERMIT NO
BLOCK TRACT / INDUSTRIAL
WASTE APPROVAL
O OF
SIZE OF LOT ,�77X!ZPOW ON LOTS\ CHARG
USE OF JJ
BUILDINGS .�--Q��L' I CONNECTION CHARGE F E
NO. DESCRIPTION OF WORK FEE
REIMBURSEMENT FEE
HOUSE SEWER CONNECTING TO
PUBLICSEWER @ $ 350 RECEIPT NO. DATE BY
HOUSEHOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 100
CONNECT ADDITIONAL BLDG.OR EXCEPTION ECORDED
WORK TO HOUSE SEWER 1 00
ALTER OR REPAIR EXISTING NO D E IBY
_SEWER OR DISPOSAL SYSTEM 1 00
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1 00 CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR } Q'
PITS AND/OR DRAINFIELD 2.00 STATION DEPTH
CESSPOOL—DRYWELL —�—
SPECIAL CONDITIONS ONLY 2.003L!5. 115 /AlMANHHOLE REFERENCE LOWER
TYPE OF CONNECTION-, � LENGTH FROM
OWNERS PERMIT $ 1 00 1 c� _ . CP Lam/ ML TOP L
AUTHORIZATION TOTAL FEES A;', G, QiC/ lyi�0'025s7"Y
I HAVE-THIS DATE CONTRACTED WITH THE HEREIN NAMED'
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO THE PUBLIC•-- SEWER
t L
SIGNED THIS._....._. ----_DAY OF-------------_------------__----14__--- NEW HOUSE SEWER tc�G C
OWNER OR t CONNECT ADDITIONAL
OWNERS AGENT------- __-------_------ BUILDING OR WORK
SEPTIC TANK,SEEP.PIT(S)
ADDRESS - ----------- ------..._- ----__-_--------.-•• --_-----.---- _--•-- i AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI• CESSPOOL❑ DRYWELL
CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER,REPAIR,SEWER OR
REGULATING PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND
DISCONNECT PLUG
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOPLUGAND
AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN-
ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS El
SIGNATUREC7C SEEP PIT(S)� CESSPOOLS E]OF PERMITTEE-_-___�+�.._..-__
76A642A•..663 7/53 PW-4&A.W! ^ K