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76A 6420 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION FADDRESS
G r i
JOHN A. LAMBIE, COUNTY ENGINEER 647--14
COLEMAN W. JENKINS. SUPT. OF BUILDING �•� p ate/
�F R APPLECANT Tt, FILL IN F WOW—
(PRINT OR TYPE ONLY} T I DESCRIP ION._ LOT NO , OWNER 1 � :, -0'g
,{'q 7 .ADDRESS
BLOCK. _r .TP.AC,7. /T ?„�i,. t ! MAIL.--_ � _ _ � 1 - 2--
oc
NO. OF BLDGS:.
SIZE OF LOT NOW ON LOT - CITY " TEL. NO. LS—,-772-
USE
—,-7 ( a-
USE OF 1 i\1 _ _ ,
° l Ut5'RIGi Y'J GRJUP GLASS ?v1AP pROL S E0 t Y
BUILDINGS BK Po
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.:.O NTRACT'OR �`-`a�'�,.,/\,
ACDRESS ^ .� .(r: �t'_ c¢✓. .�[,�Ldi! -- CONNECTION DATA
.� . ,pl "TEL NO_, .r :: STA74PN ...,1 �,', �%. DEPTH
CITY
STATE ''j j) LPC ., ,_A ��� UPPER
LICENSE NO..,,^sir tj CLASS ) tr MANHOLE REFERENCE - � .: k { -.
-- - ---- --- y - - -
NO. .DESC?RIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM �.
�HOIJSF.SEWER CONNECTING T6 _.----._-- --� .; Y. CURB P,L. M.L.TO P.L. �
Pu BI I`SEWER L� .rasotT' - L-- - __-'-
0.
SEPTIC fANK SEEPAGE PIT OR - . � � -"�Z,. JOB NO
PITS AND OR DRAINFIEL.D @' $f0.00 CO IMP. NO.i -.-._
HOUSE SEWER CONNECTING TO
TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL YS<EM
' 4 S3.00
NN"CTADDT_ONAB-LDGOR _ .
ppSS,
.O HOUSE SEWER $3.00
OVERFLOW 5 LPAGE.PiT DRAINFIELD
EXTN.,C65 POOL,DRYWEI.:L.MA++iHOLE� $5;00 '
— - L -- -- -- -��— --
AL1 ER.R_EPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING0
SEWER OR ISPOSAL SYSTEM + $3.00. - _______. _-
.._ - - SYSTEM -. STA TE.ENCROACH ME.NT Pyf
PERMIT NO, !
INDUSTRIAL
WASTE APPROVAL
_
OWNER'S PERMIT Oo __ -.______--._— c HARGes
1 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRI Br'U EXISTING DWELLING - p:�_'p_�s____.-._-__.-
TO THE PUBLIC SEW E °�'"�y ���. -p� APPROVALS DATE INSPECTORS SIGNATURE
SIGNED THIS. DAY OF
OWNER OR � �-.1.. ^S .I . fJ NEW HOUSE SEWER.__-__..
OWNERS AGENT
CONNECT ADDITIONAL -�
ADDR£5 BtJ 11 OiNG OR WORK _SEPTIC TANK,SEEP.PiT(S)
1 HEREBY ACKNOWLEDGE THAT ( HAVE READ THIS APPLICATION AND/vRDRAiNF4E1D j
AND
TATE THAT THE ABOVE IS CORRECT AND AGREE. TO :COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL �.� ORYWELL
HEREBY CERTIFY THAT i AM PROPERLY REGi.STERED AND'OR A YER,REPAIR,SEWER OR
!-E NSED AS REQUIRED BY L.OS ANGLES CC�A,7TY .AND STATE OF SEWAGE DISPOSAL SYSTEM I
C.A�IFORNIh 6R TH A7 1 AM ifiE .LEGA?.sE>WN R CF', AND ItdTEND TO - -"- --- --`---- --
DI3CdNNEI:T P..'IU AND
R-3;DE IN, THE OV. DESCRIBED R S DE T RR ,ERTY. ABAPd O�*N HOu E EWER
S GNATVR.E of y^ f°^
OF PERM"
BACKFI.L L SEPTIC TANKS .__.-__-__
'1"-'- --'------ SEEP,PIT{S) ❑ CESSPOOLS [31
-VALIDATION JACK R. ALLEN
SUPERVISING MECHANICAL ENGINEER
CK.. M..O: CASH