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S&E-663 3-55 APPLICATION YOR PERMIT
DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL
Department of County Engineer
County of Los Angeles BUILDING
YVM.J. FOX, COUNTY ENGINEER ADDRESS J
CASSATT D. GRIFFIN, SUPT OF BUILDING LOCALITY
FOR APPLICANT TO FILL IN NEAREST
CROSS ST
LEGAL / D• 1 ,
DESCRIPTION LOT NO. OWNER
BLOCK TRACT MAIL
ADDRESS
NO OF SLOGS.
SIZE OF LOT NOW ON LOT i CITY TEL. NO
USE OF, `
BUILDINGS 4 DISTRICT NO. OUP �, MAP
CONTRACTOR
7� 1
RK/D, 5 I �\ 1 1PC
ADDRESS CONNECTION DATA V 11
CITY TEL. NO. O 7 STATION4 1 DEPTH
/ !J " STATE MANHOLE REFERENCE O UPPER
REGISTRATION NO. sS �p COUNTY
NO DESCRIPTION OF WORK FEE
USE SEWER CONNECTING TO `' TYPE OF CONNECTI LENGTH FROM
PUBLIC SEWER Q $ 3 50
S V Y CURB P L M L TO P L
HOUSE SEWER.CONNECTING TO
PRIVATE DISPOSAL SYSTEM 100 _
CONNECT ADDITIONAL BLDG. OR P C NO
WORK TO HOUSE SEWER 1 00 CO IMP NO JOB NO
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM 1 00 TRUNK PERMIT NO ROAD PERMIT NO
DISCONNECT-AND ABANDON SEWER STATE ENCROACHMENT
AND/OP. DISPOSAL SYSTEM 1.00 PERMIT NO.
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 300 INDUSTRIAL
CESSPOOL-DRYWELL WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2 00 CHARGES
CONNECTION CHARGE FEE
PERMIT OWNER'S S t 00 -
AUTHORIZATION TOTAL FEE 55 REIMBURSEMENT FEE
TRACTORHAE TTOS CONNECTDATE ONTRTHEA ABOVEWDESCR BED EXIITH THE STING IN MED DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER ,
SIGNED THIS_,,,DAY 9 NEW HOUSE SEWER /
OWNER OR CONNECT ADDITIONAL
OWNERS AGEN T
- BUILDING OR WORK
SEPTIC TANK, SEEP, PIT(S)
ADDRESS '� AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLIC N CESSPOOL[IDRYWELL[3 -
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. - -
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR SEWAGE DISPOSAL SYSTEM
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❑
SEEP. PIT(S) ❑ CESSPOOLS -�T
SIGNATURE -
OF PERMITTEE -
WILLIAM J.FOX.COUNTY NGINEER VALIDATION R.A.WOOD, CHIEF PLBG. INSPECTOR
LALa
' 40-2 2 S 4A MDU 1 3 4 4.5 0 �
V I� J