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8&H-663 3.35 APPLICATION PERMIT
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DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL
Depm ent of County Engineer
County of Los Angeles • ADDRESSG v Z_
WM.J. FOX, COUNTY ENGINEER
CASSATT D. GRIFFIN, SUPT DR BUILDING LOCALITY � ,- f�
NEAREST
FOR APPLICANT TO FILLIN CROSS ST. I�. ra
LEGAL
DESCRIPTION LOT NO. OWNER (.�! ,/ ��d��� •Y�
BLOCK TRACT !! MAIL
/
ADDRESS ��,/
NO OF BLDGIS.
SIZE OF LO n NOW ON LOT / CITY TEL NO
USE OF Of -'
BUILDINGS r^ DISTRICT N0. GROUP MAP
CONTRA if ��Gy�v 'OSIS/ 15 I� �P • ..
ADDRES �� CONNECTION DATA v
r
NO �j<='' �5 STATIONz DEPTH 0
//''
DS TATE MANHOLE REFERENCE
REGISTRATION NO. ✓�•L ❑ COUNTY LOWER
NO DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO TYPE OF CONNECTION LENGTH FROM
PUBLIC SEWER Q $ 3 50 c �_ P L M L TO P L
-� HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1 00 _
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/OR DISPOSAL SYSTEM 1 00 PERMIT NO.
SEPTIC TANK, SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 2 00 INDUSTRIAL
CESSPOOL-DRYWELL WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2 00 CHARGES
OWNER'S
PERMIT s 1 00 CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE 4, REIMBURSEMENT FEE
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED CON- APPROVALS DATE INSPECTOR'S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEV _
SIGNED THIS D OF
� ! NEW HOUSE SEWER
OWNER O - CONNECT ADDITIONAL l
OWNERS A BUILDING OR WORK
7 SEPTIC TANK,SEEP, PIT(S)
ADDRESS-44::, leT' AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE I HAVE READ THIS APPLICATION CESSPOOL ElDRYWELL❑
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
IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR
LICENSED AS REQUIRED BY LOS ANGELES COUN ND STATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT I AM THE LEGAL OW F THE ABOVE ABANDON HOUSE SEWER
DESCRIBED RES IE fF7/1/A//Lj/�j�•�OPE BACKFILL SEPTIC TANKS❑ 1�,
1110-
�rG SEEP. PITS) ❑ CESSPOOLS I -zj&00 X r
SIGN
ERMI T E
W LI J.FOX.COUNTY ENGINEER VALIDATION R.A.WOOD. CHIEF PLBG. INSPECTOR
to 9 0 9 U-) OCT17 4 4.5 0
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