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COUNTY OF LOS ANGELES SEWER—SEWAGE DOSPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DMSION BUILDING t�9 f iJ {
JOHN A, LAMBIE, County En eer ADDRESS (/
WILLIAM IL JENSEN, Supt of Building_ LOCALITY
- - NEAREST
e C
FOR APP)UCANT TO FILL IN CROSS sr.
LEGAL OWNER
DESCRIPTION LOT N0. ($
BLOCK TRACTS r� G LI�sMAIL
/� A DRESS
110.OF BLDGS. g /
SIZE OF LOT NOW ON LOT a`'tti'D CITY TEL. NO
USE OF
BUILDINGS DISTRICT NO. GROU MAP P'SPROCE ED BY
CONTRACTORAIK
ADDRESS CO O DATA
CITY f% �"IEL.N0. ��-2 g STATION D DEPTH
STATE MANHOLE REFERENCE
REGISTRATION NO. B COUNTY', LOWER
No. DESCRIPTION OF _ FEE
HOUSE SEWER CONNECTING TO d�
PUBLIC SEWER @ $3.00 TYPE OF CONNECTION LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR Y. CURB P.L. N.L TO P.L.
PITS AND/OR DRAINFIELD @ $8.00
OVERFLOW SEEPAGE PIT,DRAINFIELDa
EXTN. CESSPOOL DRYWELL 52.00
HOUSE SEWER CONNECTING TOP.C.NO. O
PRIVATE DISPOSAL SYSTEM @ $1.00 CO IMP. NO. JOB NO. U
CONNECT ADDITIONAL BLDG.OR �l TRUNK PERMIT NO. ROAD PERMIT NO. 0'
WORK TO HOUSE SEWER S1 00
ALTER,REPAIR OR ABANDON HOUSE STATE ENCROACHMENT 0
SEWER 0 DISPOSAL SYSTE @ St 00 PERMIT NO V
INDUSTRIAL UJ
CL
WASTE APPROVAL to
CHARGES ?
OWNEWS PERMT S 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
DATE A CONTCT WITH THE HEEIN NAMED CN-
TRACTOR TO CIONNECT THE ABO E DESCRIBED EXIST NG DWELLING APPROVAIS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER / �� _
SIGNED THI19- NEW HOUSE SEWER /Aq
OWNER OR CONNECT ADDITIONAL
OWNERS AGEN BUILDING OR WORK
ADDRESS , SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I, HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEIJ
I HEREBY CERTIFY THAT 1IFY THAT I AMLEGA
REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS LES AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I A E LEGAL OF THE ABOVE
DESCRIBED RESIDENTIAL PE ` BACKFILL SEPTIC TANKS ❑
SIGNATURE SEEP.PITS ❑ CESSPOOLS
OF PERM]
ALIDATION ROBERT A. WOOD
cX n.0. CASH SUPERVISING MECHANICAL ENGINEER
Uri 06 7 4 1 Uo JAN 5 1 0 0 5.a G
t
— —�_
DEPAIVrMENT OF COUNTY ENGINEER "SEWER—SEWAGE DISPOSAL
DIVISIQN OF BUILDING AND SAFETY a Y . PERMIT A PLIC ION
COUI ITV OF LOS ANGELES .11
WILLIAM J. FDX. COUNTY ENC31NEER BUILDING
I ADDRESS '7 [/ 7
O FOR APPLICAN O FIL N LOCALITY ,
BUILDING NEAREST �� Z
ADDRESS CROSS ST.
LOCALITY DISTRICT N0. SERIAL NO. 'PERMIT NO.
� ♦
NEAREST ~r /ao
SY-3 S
'CROSS ST � e
RECEIVED BY,4 Ready for Inspection D2,102
ISSUED
GWNER � !/
MAIL USE ZON OCCUPANCY MAP
ADDRESS• ,
BK PG
CIT EL.NO. _ 7 / �s
CONTRACTOR /I `�
CO.IMP.N0.
ADDRESS
JOB NO. —
CITY t
TIL NO. TRUNK PERMIT NO. ~--
STATE
REGISTRATION NO. �Lj. COUNTY ROAD PERMIT NO. —
LEGAL STATE ENCROACHMENT
DESCRIPTION LOT NO. PERMIT NO.
BLOCK TRACTIF ! INDUSTRIAL
WASTE APPROVAL
SIZE LOT _ -2:2,0 NOW ONF F LOTS ! CHARGES
USE OFF
BUILDINGS CONNECTION CHARGE FE
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO / REIMBURSEMENT FEE
PUBLICSEWER 0 $ 3.50 �v RECEIPT N0. DATE BY
HOUSE SEWER CONNECTING TO
PRIVATEDISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.OR EXCEPTION ECORDED
WORK TO HOUSE SEWER 1.00
ALTER OR REPAIR EXISTING NO• I DA E I BY
SEWER OR DISPOSAL SYSTEM 1.00
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1.00 CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 240
CESSPOOL—DRYWELL STATION '� D DEPTH
SPECIAL CONDITIONS ONLY 2.00FERENCE ,�Jr!, ypJR //
7 �NIiPPEF37E
TYPE OF CONNECTION—..;, LENGTH FROM /
OWNERS PERMIT $ 1 00 P Lj M.L.TO P.L.
AUTHORIZATION TOTAL FEE /57 7 0%
IHAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DE CRIBED EXISTING APPROVALS I NSPECTOR'S SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER
SIGNED THIS.,Z-" "Y-' Y OF_ ___ .__..19-11U NEW HOUSE SEWER
OWNER OR BUIILDING OR WORKECT OWNERS AGENT-= - ,�/��y_�...- - -
I� _- -_�i�P1 SEPTIC TANK,SEEP.PIT(S)
ADDRESS.... .. ._ Q.. ..... ..... .. ��%%ii�i AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT 1 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
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED `
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTYDISCONNECT PLUG AND
AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN- ABANDON HOUSE SEWER
ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS
SIGNATURE SEEP.PIT(S)[ CESSPOOLS
OF PERMITTEE.._
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