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`.S&EAB 312-54 APPLICATION- FOR■ PERMIT � 1
DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Department of County Engineer
County of Los Angeles ADDRESSG (p U T
WM. J. FOS;. gOUN7Y ENGINEER
CASSATT D. GRIFFIN, SUPT OF BUILDING LOCALITY.
FOR APPLICANT TO FILL IN NEAREST
CROSS ST.
LEGAL 7 �
DESCRIPTION LOT NO l OWNER
BLOCK TRACT L� u MAIL /
(�
-Fix
/ NO OF BLDGS. ADDRESS
_
SIZE OF LOT O x ` 3 NOW ON LOT CITY TEL NO
USE OFq
BUILDINGS 1 Z L
DISTRICT N I G I MAP
BK PG
CONTRACTOR
ADDRESS 6 CONNECTION DATA
CITY , TEL. NO. (y Ij^V STATION DEPTH
STATE MANHOLE REFERENCE
REGISTRATION NO. 0 /1�� ❑ COUNTY UPPER LOWER
1 TYPE OF CONNECTION LENGTH FROM
No. DESCRIPTION OF WORK FEE Y CURB P L. �y.M L TO P.L.
HOUSE SEWER CONNECTING TO ��>�"�
_PUBLIC SEWER "Q $ 3 50
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 100
CONNECT ADDITIONAL BLDG OR / �- CO 151P N0. JOB NO
WORK C HOUSE SEWER 1 00
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
CONNECTION CHARGE FEE
OWNERS PERMIT g 1 00
AUTHORIZATION TOTAL FEE - REIMBURSEMENT FEE
TRACTORHAVE T TOS CONNECT DATE CO
ONECTONTRTHEA ABODVEWDESCR BED EXISTINGITH THE HEREIN A DWELLING APPROVALS DATE INSPECTOR S SIGNATURE
TO THE PUBLIC SEWER
NEW HOUSE SEWER
SIGNED THIS DAY OF 19
OWNER OR CONNECT ADDITIONAL "a{l
OWNERS AGENT BUILDING OR WORM. (J➢RT! 1111 .
�� SEPTIC TANK, SEEP, PIT(S)
ADDRESS AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL[-IDRYWELL❑
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
I HEREBY CCRTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIAL PROPERTY. \ BACKFILL SEPTIC TANKS[ISIGNATURE
SEEP.PIT(S) ❑ CESSPOOLS❑
OF PERMITTEE
WILLIAM J. FOX, COUNTY ENGINEER VALIDATION
r
BY ..,kC0 4 6 OB 9`; 'JUN 13 4 2.0 0
DEPUTY DEPUTY
BY BY
�"® DEPUTY DEPUTY
DEPARTMENT OF COUNTY ENGINEER SEWER-SEWAGE DISPOSAL 1
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER BUILDING A�
CASSATT D. GRIFFIN SUPT OF BUILDING ADDRESS ;Z AZ
FOR APPLICANT TO FILL, IN LOCALITY
BUILDING NEAREST
ADDRESS CROSS ST .� Q��
DISTRICT NO A SERIAL NO. PERMIT N0
�� ���
LOCALITY (- �j
NEAREST c b �` " �S
CROSS ST.
I RE�RCE}��I�VyED Y Ready for Inspection aDATE ISSUED
OWNER �J pFIUT ,.!, ���
MAIL �/ w USE ZONE OCCUPANCY MAP
ADDRESS /S /1L- -�j J BK PG
CITY &"�TEL.N0.
CONTRACTOR Al -/ u 1 CHARGES REIMBURSEMENT FEE-
ADDRESS �,�o 7�1lJJ n��-�� REQUIRED
�`�. NOT REQUIRED
CITY TEL.I `/ Z 510,0 7 )OB NO. CONNECTION EEE
STATE
REGISTRATION NO ��� N CID NTY p r CO. IMP.NO
LEGALRECEIP\O. I DATE I BY
ry
DESCRIPTION LOT NO. f� '7z A
BLOCK TRACT '_-s'p® '�;z WAIVER FOR RECORDING
SIZE OF LOT NO OF BLDGS. RECEIPT NO DATE BY
NOW ON LOT
USE OF .41
—BUILDINGS �s( �'_ ��C>�
TRUNK PERMIT NO.
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO ROAD PERMIT NO.
PUBLICSEWER Q $ 3.50
HOUSE SEWER CONNECTINGTO STATE ENCROACHMENT
PRIVATE DISPOSAL SYSTEM 1.00 I PERMIT NO.
CONNECT ADDITIONAL BLDG.OR INDUSTRIAL
WORK TO HOUSES EWER 1.00 WASTE APPROVAL
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM 1.00 CONNECTION TA
DISCONNECT AND ABANDON SEWER \\
AND/OR DISPOSAL SYSTEM 1.00 I STATION DENTH
SEPTIC TANK,SEEPAGE PIT OR lk
PITS AND/OR DRAINFIELD 2.00 I MANHOLE REFERI!NCE \
CESSPOOL—DRYWELL UPPER 0 LOWER
SPECIAL CONDITIONS ONLY 2.00 I TYPE OF CONFECTION LENGTH F OM
Y ,,CURB P.L. M.L.TO P.L
OWNERS PERMIT $ I I 00
AUTHORIZATION I TOTAL FEE 1 �.100
CO THAVE THIS DATE CONTRACRACTOR TO CONNECT THTE ABOVE D SCRIBEDWITH THEI EXIISTING ED APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER
SIGNED THIS___ . ._..DAY OF NEW HOUSE SEWER r
--=-- 19�5-'d —
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT!r/! ! ...GhrCiGf/lrYiS'i�P•1ase BUILDING OR WORK
.........................-
� . SEPTIC TANK,SEEP.PIT(S)
ADDRESS r,.. !.__!:Y_ Q ✓�................... AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI- CESSPOOL E] DRYWELL
CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER,REPAIR SEWER
REGULATING PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED DISCONNECT PLUG AND
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOPLUGAND
AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN-
USESEWER
ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY BACKFILL SEPTIC TANKS
t - SEEP.PIT S [] CESSPOOLS❑
E
SIGNATURl�Q�r} n - , fry,+5.✓ i
OF PERMITTEE----•::--;-------------•---=-'----: ------------------------------
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