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76A642D APPLICATION FOR PERMIT
6A642
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BU ILD INGO / ��•�
JOHN A. LAMBIE, County Engineer ADDRESS 6!
WILLIAM A. JENSEN, Supt of Buildmg
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST , cl
LEGAL L/
DESCRIPTION LOT NO OWNER
`�'CgT�Y //y , [.,.s—
MAIL
BLOCK TRACT �J V oJ� 7 ADDRESS
/NO
OS
SIZE OF LOT NOW ON LOT
CITY TEL NO
USE OF DISTRICT NO GROUP MAP PROCESSED BY
BUILDINGS ��
CONTRACTOR _e -.,��V[,� �./a O� G K 12
ADDRESS 3e4 7 CONNECTION DATA
CITY TEL N Z/ — �v STATION /� -14-92. ��E-TH
REGISTRATION NO C-
STATE COUNT (_E 3 / UPPER
� MANHOLE REFERENCE ''''''7'7
2� Y � Z_
NO DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FR M
HOUSE SEWER CONNECTING TO Y CURB P L M L TO P L �J
PUBLIC SEWER @ E5 00
SEPTIC TANK SEEPAGE PIT OR / P C NO O
PITS AND/OR DRAINFIELD @ $1000 CO IMP NO JOB NO V
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO
PRIVATE DISPOSAL SYSTEM @ $3 00
CONNECT ADDITIONAL BLDG OR RECORD INSTR NO DATE 0
WORK TO HOUSE SEWER @ $3 00 SV.
OVERFLOW SEEPAGE PIT,DRAINFIELD W
EXTN,CESSPOOL,DRYWELL MANHOLE @ 3500
ALTER,REPAIR OR ABANDON HOUSE HWY OR ST WIDENING N
SEWER OR DISPOSAL SYSTEM @ 3300 STATE ENCROACHMENT Z
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT $ 21 00 CHARGES
AUTHORIZATION I TOTAL FEE 1 71
61-.0 CONNECTION CHARGE FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIB EXISTING DWELLING APPROVALS
TO THE PUBLIC SEWER DATE INSPECTOR 5 SIG ATURE
SIGNED THIS D Y OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
SEPTIC TANK,SEEP PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I M THE LEGff�ZRTY
INTEND TO DISCONNECT PLUG AND
RESIDE IN THE AB VE ESCRIBED ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMITTEE SEEP PIT(S) ❑ CESSPOOLS ❑
VALIDATION ROBERT WOOD
SUPERVISING MECHANICAL ENGINEER
CK M O CASH
ems:2-67,92 JM 19 1 0 D 7.00- 0
I01' .
DEP"XMF,NT OF COUNTY ENGINEER, SEWER-SEWAGE DISPOSAL
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTYLOS ANGLES ` BUILDING ��a(
WILLIAM J. FOO E
X, COUNTY EN[3]NEER I ADDRESS
FOR APPLIC T O FILL N LOCALITY
BUILDING NEAREST
ADDRESS -4A4 CROSS ST.
LOCALITY •}e _ _ DISTRiCT NO. SERIAL NO. PERMIT NO..
[
NEAREST A
I� A ' J
CROSS ST. (�
RECEIVED BY Ready for Inspection DATE ISSUED
OWNER
MAIL /7 �. USE ZONE MANCY, MAP
ADDRESS be I //gK /yPG
CITY COQ T�EL.N0.t 1 S
CONTRACTOR -/L CO.IMP.N0. /3t S
ADDRES
JOB N0.
CITY j , EL.NO. TRUNK PERMIT NO.
REGISTRATION NO. /,�.'��� Q � ® COUNTY ROAD PERMIT NO.
LEGAL
D SCRIPTION LOT NO. -��JQ� /00 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
SIZE OF LOT NO.OF BLDGS. C ARG ES
NOW ON LOT_
USELDINGS CONNECTION CHARGE FEE
N0. DES RIPTION OF WORK FEE
REIMBURSEMENT FEE
HOUSE SEWER CONNECTING TO
PUBLICSEWER 0 $ 3.50 RECEIPT NO. DATE BY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.OR EXCEPT ON RECORDED
_WORK TO HOUSE SEWER 1.00
ALTER OR REPAIR EXISTING NO. I DATE I BY
SEWER OR DISPOSAL SYSTEM 1.00
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1.00 CONNE TION DATA
SEP IC TANK,SEEPAGE PIT OR /
PITS AND/ORDRAINFIELD 2.00 STATION t' ..GS J DEPTH (p
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 2.00 /O M:�r HOLE REFERENCE G
UPPER
TYPEIOF CONN ON LENGTH FROM23
OWNERS PERMIT I 00 CURB --Pita M.L.TO P.L.
AUTHORIZATION I TOTAL FEE
1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER
SIGNED THIS- fi .-.DAY OF..- !2-✓�1_�^_.(t�9 NEW HOUSE SEWER
OWNER OR ` � .f'/► _ CONNECT ADDITIONAL
OWNERS AGENT. .fes/ ___.. _LJ �'Smn BUILDING OR WORK
a EPTIC TANK,SEEP.PIT(S)
ADDRESS.-. _. ._A_� !�•--_�!n;---�
t: ND/OR DRAINFIELD
�- -
I HEP,EBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI- CESSPOOL E] DRYWELL
CATIONAND 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
I HEREBY CERTIFY THAT IAM PROPERLY REGISTERED DISCONNECT PLUG AND
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOUSE SEWER
AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN-
ER OF THE ABO DESCRIBED"IDE. PRO RTY•1/y BACKFILL SEPTIC TANKS�
SEEP.PIT(S)E] CESSPOOLS IR �GA (� c SIGNATUREOF PERMITTEE_ .._._
76A642A 663 7/53 V
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