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0 I @ R.• APPLICATION FOR PERMIT
II "3 9.88
DIVISION OF BUILDING AND SAFETY SEWED—SEWAGE DISPOSAL.
Deportment of County Engineer
County of LOS Angeles BUILDING
WM.J. FOX, COUNTY ENGINEER ADDRESS
CASSATT D.GRIFFIN, SUPT OF BUILDING LOCALITY
FOR APPLICANT TO FILL IN NEAREST
CROSS ST. .if/!'1- ti.OZ-A
LEGAL / //''
DESCRIPTION LOT NO (� � OWNEIIctli 1-00-ZI&�12CRe0J4
BLOCK TRACT ' MAIL
•S ADDRESS.5v,1',j 11 yy��1• l C-.t& le clt %I J cl,
SIZE OF LOT DD NOWOONBLOTS CITY , 4-t (Ia j l3 u TEL. NO
USE OF
BUILDINGS DISTRICT NO �GRpO�+UP MAP
CONTRACTOR ' �, ,+ // BK PG
/ ? 7
ADDRESS CONNECTION DATA OC
r r
CITY TEL NO
/�- ❑ STATIONDEPTH /
j ( 4 COUNTY
MANHOLE REFERENCE/ 9 r' UPPER
(/
REGISTRATION N0. p( �G
NO. DESCRIPTION OF WORK FEE
TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TOY KAIR29 `p.L— M.L TO P L. �..J
PUBLIC SEWER Q $ 3 50 3J-0
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 100 _
CONNECT ADDITIONAL BLDG. OR 'J/� P C NO.
WORK TO HOUSE SEWER 1 00 CO IMP NO. f/Q,f JOB NO
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM 1 00 TRUNK PERMIT NO. ROAD PERMIT NO�/Q�j�
DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT
AND/OR DISPOSAL SYSTEM 1 00 PERMIT NO
SEPTIC TANK, SEEPAGE PIT OR INDUSTRIAL
PITS AND/OR DRAINFIELD 2 00 WASTE APPROVAL
CESSPOOL- DRYWELL
SPECIAL CONDITIONS ONLY 2 00 CHARGES
OWNER'S pCONNECTION CHARGE FEEPERMIT � I o0
AUTHORIZATION I TOTAL FEE REIMBURSEMENT FEE
IS
THIS DATE CONTRACTED WITH, THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPE TOR'S SIGNATURE
TO THE PUBLIC SEWER
SIGNED THIS DAY OF 19SJ NEW HOUSE SEWER �� 4
OWNER OR / CONNECT ADDITIONAL
OWNERS AGENT �v✓ �` BUILDING OR WORK
ADDRESS SEPTIC TANK SEEP, PIT(S)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL[IAND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER. REPAIR, SEWER OR
PLUMBING AND SEWER '
SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIF T AT I AM PROPERLY PEGISTERED AND/OR
LICENSED AS REQ E BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND _
CALIFORNIA OR AT 1 AM THE LEGAL OWNER OF THE ABOVE ABANDON HOUSE SEWEP
DESCRIBED RESID NTJAL PROPERTY. BACKFILL SEPTIC TANKS❑
SEEP. PIT(S) ❑ CESSPOOLS❑
SIGNATURE
OF PERMITTEE
WILLIAM J.FOX.COUNTY ENGINEER VALIDATION R.A. WOOD, CHIEF PLBG. INSPECTOR-
_,AC0 6 9 6 E AUG 22 4 4.5 0 �'