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APPLICATION `FOR PERMIT 1
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
-
BUILDING AND SAFETY DNI:IION BUILDING y
IOHN A. LAMBIE, County Engines ADDRESS
CASSATT D. GRIFFIN,Supt of Building LOCALITY -
NEAREST
FOR APPLICANT TO FILL IN I_CROSS ST. _
LEGAL
DESCRIPTION LOT NO.`- _ ,; _. ;' [ 1 r OWNER t
e
BLOCK TRACT ADDRESS ^
NO.OF BLDGS. Y
SIZE OF LOT NOW ON LOT - CITY 7E L.N0, f
USE OF
BUILDINGS ! DISTRICT N0, GROUP MAP PROCESSED BY
BK PG
CONTRACTOR
ADDRESS r r a m,z t ra.,� CONNECTION DATA
Bryant n' .i eta m
CITY d;l �O_nte TEL.NO. vG 8-6"`6q 4f,011 �� DEPTHSTATE
REGISTRATION NO. COUNTY MANHOLE EFERENGE y -' - UPPER,
NO. ! DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING T9 dd r•-"`;
PUBLIC SEWER $9.00 I
SEPTAN TANK.SEEPAGE PIT OR TYPE OF CONNECTION LENGTH FROM
s _ y
PIT'S AND/OR-DRAINF_IELD @ $3.00 Y. CURB P.L. AI,L.70 P.L.
OVERFLOW SEEPAGE PIT.DRAINFIELD 1r
EXTN.,CESSPOOL,DRYWELL,MAN HOLE
@ $2:00 -
HOUSF SEWER CONNECT:NG To — F P.C.NO.
PRIVATE DISPOSAL SYSTEM C�3 $1.00 ""`"`""' CO.IMP.No,
_/ r T----�'' JOB 14 0,
_ - I �!
WORK TO HOUSE SEWER Q $1.00
CONNECT ADDITIONAL BLDG.OR PERMIT PERT N0. ROAD PERMIT N0.
ALTER,REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
SEWER OR DISPOSAL $1.00 SYSTEM — _PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OW EWS PERMIT4 �00 CONNECTION CHARGE FEE
AUTHORIZATIONTOTAL FEE � �`"�:% REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON., APPROVALS DATE INSPECTOR'S SIGNATURE
TRACTOR I'D CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER.
SIGNED THIS DAYF � 19® NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNER$AGENt__g.4- — T
BUILDING OR WORK
ADDRESS '.%i SEPTIC TANK,SEE?,PIS)
., AND/OR DRAINFIELD
I HER EBY/f CKNOWIEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND.AGREE TO COMPLY CESSPOOL[❑ DRYWELL
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER, REPAIR, SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY 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 RESIAE471AY4 PROPERTY. BACKFILL SEPTIC TANKS❑
SEEP.PIT(S) I] CESSPOOLS
SIGNATURE � /' .�..- _- �- ,.i .;;
OF PERMITTE
;.
VALIDATION M,
A.WOOD
cx. M,0. CASA SUPERVISINGMECHANICAL ENGINEER
-�f
.F
24650 INSERTS
CE
71BAc ��42D APPLICATION FOR PERMI C
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS
IOA£I A. LA,MBIE. County Engineer
LI,Ia�M A. JENSEN, Supt of Building LOCALITY °
NEAREST Tom"
FOR APPLICANT TO FILL IN CROSS ST,
LEGAL .3. < -'
DESCRIPTION LOT N0. ei
$.- - +z OWNER
.BLOCK TRACT MAIL
_ADDRESS
NO.OF BLDGS. c•!'
SIZE OF LOT - NOW ON LOT I•- CITY o __ TEL. NO. -
BUILDINGS'OF * L.-C"
DISTRICT NO. -GROUP
BK
MAP PG �4FR9CESSED BY
CONTRACTORi ri-�•1 i ! ,+$ ..laV r �-�' �: OJ
c''6i-.;�` j_.. - -
7
ADDRESS - , ;- CONNECTION DATA
CITY y TEL.140. S Aa ONS DEPTH �✓
Q.
STATE MANHOLE REFERENCE gUPPEj3=
REGISTR.AT'TON NO. j` �,_ -COUNTY_
NO. 1 DESCRIFTION OF WORK FEE
HOUSE SEWER CONNECTING TO -
PJBLICSEW'ER @0 $3.00 TYPE OF CONNECTION LENGTH FROM "? ,
SEPTIC TANK,SEEPAGE PIT OR Y. CURB P.L. M.L.TO P.L, f
PITS AND/OR DRAINFIELD @ $3.00 r;
OVERFLOW SEEPAGE PIT.
EXTN„ CESSPOOL. DRYWELL i 52.00
HOUSE SEWER CONNECTING TO P- ,� - P.
PRIVATE DISPOSAL SYSTI'.. @ $1,00 CO.IMP.N0. ,- .YOB N0. IN
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT NO, r �: O
WORK TO HOUSE SEWER « $1.00 '
ALTER, REPAIR OR ABANDON HOUSE STATE ENCROACHMENT p$
SEWER O ISPOSAL SYSIE _ @ $1.00 _PERMIT NO.
INDUSTRIAL
I _ WASTE APPROVAL _
{ CHARGES
OVMER'S PERMIT $ CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE I A r cr REIMBURSEMENT FEE
IHAVE AT TRACTOR TO THIS
THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER. -
SIGNED THIS DAY OF 19- NEW HOUSE SEWER
OWNER OR - l CONNECT ADDITIONAL
OWNERS AGENT �i��-''!" BUILDING OR WORK
SEPTIC TANK,SEEP,PIT($)
ADDRESS AND/OR ORAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL I] DRYWELL
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGEDISPOSALSYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/011 DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATEN-:0F .ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM THE LEGAL OWNER, OF THE ABOVE
DESCRIBED RE IENX-iAk PROPERTY. BACKFILL SEPTIC TANKS
y y. 5 EP.PIT(S) ❑ CESSPOOLS
.SIGNATURE -�
OF PERMIT T - ✓5.�✓,1 ss et .f�,�"' ,�., _ I .L;� .+ ,�4L,, f' �) ✓�;
VALIDATION ROBERT A. WOOD
CK, M.O. CASH SUPERVISING MECHANICAL,ENGINEER