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- DIVISION OF BUILDING AND:SAFETY S EW E'R®S E WAGE D 9 S P®SA L
Department of County Engineer
t County of.Los Angeles: BUILDING .` /' � `
WM. J. FOX, COUNTY ENGINEER ADDRESS �17 r, yA '1 •Jfi� �.�'�}�,_ • _
- -.
CASSATT`D. GRiF.FIPJ,.SuP'T of SUILDlNG LOCALITY
FOR,.APPLICANT TO FILL IN „NEAREST �'�
"CROSS ST,
a
LEGAL
. DESCRIPTION LOT,NO.' � � � -0WNER � Y.
BLOC .16 134 #
K - TRACT MAIL.
ADDRESS
:,NO. OF BLDGS- ""-°'� 0' das.4 K.l-`i•�
SIZE OF,LOT / NOW ON LOT
x � � CITY TEL. N0
USE.OF :'..
BUILDINGS /. .,� � ,,�. •� DISTRICT NO. .RyO�U^.P. h1AP,
CONTRACTOR � ir'L"i'C L/l.r✓9M1/.A - .� I OG4
ADDRESS 11i
CONNECTION DATA .
CITY ,,A—, TEL NO. ,/ �'^ ,STATION ' V DEPTH
- ,(NATE _ O MANHOLE REFERENC ��"/�
REGISTRATION N0. � ..�� ❑ COUNTY <L"i - OWER
- – "TYPE OF-CONNECTIgN� LENGTH FROM
NO. I DESCRIPTION.OF WORK' FEE - Y.. CURB -(P.L. J M,L.TO P.L. �(�5
HOUSE SEWER CONNECTING TO -
PUBLIC SEWER - O 8 .3.50
'HOUSE,SEWER CONNECTING TO. Pei -
PRIVATE DISPOSAL SYSTEM 1.00 Pei
`
-CONNECT ADDITIONAL BLDG, OR� - Co. IMP.. N0: JOB. NO. 3
_ ,WORK TO`HOUSE SEWER - L00
,ALTER OR REPAIR.EXISTING
SEWER OR.DISPOSAL.SYSTEM 1.00, - TRUNK PERMIT NO. ROAD PERMIT NO.
.DISCONNECT ANDABANDONSEWERSTATE ENCROA'CH:4IENT
AND/OR DISPOSAL SYSTEM 1.00 PERMIT N0. -
SEPTIC TANK, SEEPAGE PIT OR -- - - -PITS AND/OR DRAINFIEL6 2.00 INDUSTRIAL
CESSPOOL- DRYWELL - ,WASTE APPROVAL -
SPECIAL CONDITIONS ONLY 2.00 - - CHARGES
_ . T•_ CONNECTION CHARGE*FEE
' -
OWNER'S PERMI
S 1 00
AUTHORIZATION TOTAL'FEE'` RELMBURSEM10,
EPlT FEE
I' HAVE THIS.DATE.:CDNTRACTED WITH THE, HEREI N'.NAME -CON-
TRACTOR -
TO CONNECT THE ABOVE DESCRI D EXISTING DWELLING' '-�iPPRO`lpALa7 DATE INSPECTOR`S SIGNATURE.
TO THE PUBLIC',SEA'ER
t d� ` NEW HOUSE,SEWER S
SIGNED,THIS /_ DAY'OF 19'x!-
CONNECT ADDITIONAL
OWNER;
OR, _ y -, sem BUILDING OR WORK
OWNERS AGENT/7
SEPTIC TANK, SEEP, PITS)
AND/OR DRAINFIELD.
I HEREBY ACKNOWLEDGE THAT I H VE READ THIS APPLICATION CESSPOOL El DRYWELL.❑
AND .STATE THAT•-THE-ABOVE^IS CORRECT AND AGREE TOCOMPLY
WITH ALL COUNTY. ORDINANCES" AND STATE LAWS REGULATING ,pLTER,,REPAIR,-SEWER OR -
PLUMBING AND SE\HERS: - . SEWAGE DISPOSAL SYSTEM
LICENSED AS REQUIRED BY
..l HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR
DISCONNECT PLUG AND
ANGELES COUNTY. AND STATE OF
CALIFORNIA OR THAT. I AM THE LEGAL"OWNER OF- THE ABOVE_ ABANDON:HOUSE SEWER - - -
DESCRIBED RESIDENTIAL PROPERTY,
BACKFILL SEPTIC TANKS
..�.. '. :SEEP. PIT(S) ❑.CESSPOOLS..SIGNATURE
OF. PERMITTEE
WILLIAM J- FOX, COUNTY ENGINEER VALIDATION
08 4.9 5 � 4,540
DEPUTY' DEPUTY .
;:BY. BY
. .. DEPUTY ry EPUTY ..