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76A642112
APPLICATION FOR PERMIT
6A642
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION F.�:3D�:S
/� r,�
JOHN A. LAMBIE, County Engineer
WILLIAM A. JENSEN, Sup't of Building
FOR APPLICANT TO FILL IN
LEGAL
DESCRIPTION LOT NO TJ OWNER
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n MAIL
VI r
BLOCK TRACT , ADDRESS O
]� NO OF BLDGS `eg
SIZE OF LOT Il NOW ON LOT CITYTEL NO
USE OF
BUILDINGS DISTRICT NO GROUP MAP PROCESSED BY
S 09 BK 3G 6C>L0VK&'
CONTRACTOR J L 7
ADDRESS CONNECTION DATA
CITY TEL NO STATION 2--7S--J r DEPTH
REGISTRATION NO
HCOUNTYTATE MANHOLE REFERENCE `/1 C1 e c LPi'ER
JV ✓ ✓
NO DESCRIPTION OF WORK FEE TYPE OFION LENGTH FROM ? /
HOUSE SEWER CONNECTING TO Y CURB P L M L TO P L
PUBLIC SEWER @ $5 00
SEPTIC TANK SEEPAGE PIT OR P C NO r'
PITS AND/OR DRAINFIELD @ $1000 CO IMP NO .108 NO 4+
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO
PRIVATE DISPOSAL SYSTEM $3 00
CONNECT,ADDITIONAL BLDG OR 00 AFFIDAVIT WAIVEN EASEMENT RECORD INSTR NO DATE
WORK TO HOUSE SEWER @ $300
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL MANHOLE @ $5 00
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING
SEWER OR DISPOSAL SYSTEM @ $300 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT $ 2 00 CHARGES
AUTHORIZATION TOTAL FEE 00 CONNECTION CHARGE FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED XISTING DWELLING
TO THE PUBLIC SE APPROVALS DATE INSPECTOR S SIGNATURE
SIGNED THIS DAY OF -1916-1
OWNER OR NEW HOUSE SEWER / l
OWNERS AGENT_ CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
SEPTIC TANK SEEP PIT(S) Q '
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
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
LICENSED AS 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 REST NTIAL PROPERTYn ABANDON HOUSE SEWER
SIGNATURE BP
BACKFILL SEPTIC TANKS
OF PERMITTEE SEEP PIT(S)
❑ CESSPOOLS ❑
VALIDATION ROBERT A WOOD
CK M O
SUPERVISING MECHANICAL ENGINEER
CASA
��to3O73 OR 9 1 0 D 5() i-D� °'
DEPARTMENT OF COUNTY ENGINEER j SEWER-SEWAGE DISPOSAL 1
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY' ENGINEER BUILDING
ADDRESSr
J E
FOR APPLI ANT TO FI�jLL SIN i LOCALITY Y
ADDRESS I oS1 7BUILDING (/L� ./ CROSS STNEAREST. / �oZ0 GLS O'V
LOCALITY DISTRICT NO. SERIAL NO ^ PERMIT NO. c
NEAREST A 7O / .Z / S
CROSS ST
RECEIVED BY Ready for Inspection DATEISSUED
OWNER � 3
:
MAIL USE0NE OCCUPANCY MAP
ADDRE S / d�1 BK
PQ
CITY L � TEL N O
CONTRALTO CO.IMP NO 7-1— A0
ADDRESSQ '�! 7./ A1447 ,OR un
CITY TEL. 0. `�2
7R'Iuk PE4"wIT NA
STATE
REGISTRATION NO. /�w COUNTY ROAD PERMIT NO. - q y Z
LEGAL I
DESCRIPTION LOT NO—E—GS /J/Z l=f'id'//f�O STATE E Q
D 'fog
BLOCK TRACT , Z INDUST
PPROVAL
SIZE OF LOT NO OF BLDGS
NOW ON LOT ! CHARGES
USE
BUILDINGS CONNECTION CHARGEE
NO DESCRIPTION OF WORK FEE
REIMBURSEMENT FEE
HOUSE.SEWER CONNECTING TO
PUBLIC SEWER $ 350 RECEIPT NO. I DATE I BY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1 00
CONNECT ADDITIONAL BLDG OR EXC TIO RECORDED
1 00
ORK TO HOUSE SEWER
WO� NO
ALTER OR REPAIR EXISTING D E BY
SEWER OR DISPOSAL SYSTEM 100
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1 00 CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/ORDRAINFIELD 2.00 I _STATION �� DEPTH ��
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 200S-0
� , MANHO�LHR—
REFERENCE c�
TYPE OF CONN CTION LENGTH FROM y d
r)( -P L
OWNERS -PERMIT $ �' 1 00 Y CURB ML TO P L //
AUTHORIZATION I TOTAL FEE S I.>D
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED'EXISTING APPROVALS INSPECTORSSIGNATURE DATE
DWELLING 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)
ADDRESS __- _________ ________ _ AND/OR DRAINFIELD
CAT HEONRAND STATE ACKNOT,HATT THE ABOVE SLEDGE THAT I VCORRECTE READ TAND AGREIHIS E' CESSPOOL DRYWELL 'l iZ��
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 DISCONNECT PLUG AND
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOUSE SEWER
AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN-
ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY BACKFILL SEPTIC TANKS Ej "
SIGNATURE
SEEP PIT(S)[] CESSPOOLS
-
OF PERMITTEE - - - - ----- ----------------- ---------- y
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