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DEPAI(TB EN'P OF COUNTY ENGNE= SEWER—SEWAGE DISPOSAL 1
DIVISION OF BUILDING AND SAFETY PERMIT APPLI(;ATION
COUNTY OF LOS ANGELES BUILDING
WILLIAM J. FOX, COUNTY ENGINEER I ADDRESS
FOR APPLIC T TO F LIN LOCALITY
BUILDIN - NEAREST
ADORE CROSS ST. Pd .Q C►L'�[J`'1
LOCALITY
NEAREDISTRICT N0. A J SERIAL N0. PER�IIT�NO. c
Y- 1/J� //`7aL d•�c ST
CROSS ST
RE��aEl�jf�D�BY(�n Ready for Inspection �/ DATEgISSUED
OWNER /��"•l/ / Oc�A
MAIL
ADDRESS USE ZONE OCCUPANCY
BIC PG.
�r .NO. / I ��-I
CONTRACTORac. _ CO.IMP.NO. f(� C._ ~p�
ADORES JOB N0.
TEL.N TRUNK PERMIT N0.
REGISTRATION NO. �/� r` LJ COU TY ROAD PERMIT NO.
LEGALe
DESCRIPTION LOT NO. ��, /"' "J e 7 STATE ENCROACHMENT
PERMIT N0.
BLOCK TRACT Ai.�� J} WASTE APPROVA_L
SIZE OF LOT NO.OF BLDGS.
Y K / 0 NOW ON LOT- � CHARGES
USE OF �)
BUILDINGS CONNECTION CItARGE FEE
NO. DEEMKIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO REIMBURSEMENT SkE
PUBLIC SEWER S 3.50 r RECEIPT NO. DATE I BY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1:00
CONNECT ADDITIONAL BLDG.OR I E EP ON RECORDED
WORK TO HOUSE SEWER 1.00
ALTER OR REPAIR EXISTING NO• I ATE I BY
SEWER OR DISPOSAL SYSTEM 1.00
AND/ORNDISPOSAL ABANDON SEWER - 1.00 CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR- ;
PITS AND/OR DRAINFIELD 2.00 STATION DEPTH rd
CESSPOOL-DRYWELL ! ^r
SPECIAL CONDITIONS ONLY 2.00 //P' MANHOLE REFERENCE
UPPEit-_
LOWER
-TYPE OF CONNECTION LENGTH FROM r D
OWNERS PERMIT $ 1 00 y_ CURB P M.L.TO P.L.
AUTHORIZATION I TOTAL FEE G'i
1 HAVE THIS DATE CONTRACTED WIT THE HEREIN NAMED,
CONTRACTOR TO CONNECT THE ABO DESCRIBED EXISTING APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER _�//��A�
SIGNED THIS_2- AY 10-- NEW HOUSE SEWER Id •!(/r��! '�=7, `
OWNER OR - _M ! BU.NLDING ADDITIONAL
OWNERS AGE ... _:. �. _ _ _ _
r' � _ ,�yy„`� SEPTIC TANK,SEEP.PIT(S)
ADDRESS.. _._...__i.?.._�_L._ .x.'_._. .�....__..__.._..._._.___._.._. AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI CESSPOOL❑ DRYWELL
CATION AND 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 1 AM PROPERLY REGISTERED DISCONNECT PLUG AND
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOUSE SEWER
AND STATE OF CALIF NIA OR AT 1 AM THE LEGAL OWN-
ER OF THE AB VE D CRIBE ESIDENTIAL PERTY. BACKFILL SEPTIC TANKS rl ��t
SIGNATURE SEEP.PIT(S)E] CESSPOOLS
OF PERMITTE _ r?7�._.._.._._. ,
76A642A 663 7/53