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7APPLICATION FOR PERMIT
8A64YD
COUNTY OF LOS ANGELS SEWER—SEWAGE DISPOSA
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A LAME, County EnqEneor ADDRES: ffl
dfG. _I
WALIAM A MOEN, SuP't of SuEldEng
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROS: ST
LEGAL
DESCRIPTION LOT-2- OWNE
MAIL
BLOCK TRACT ADDRESS
NO OF SLOGS � a
SIZE OF LOT NOW O LO CITY TEL NO -s
USE OF DISTRICT NO GROUP MAP PROCESSED BY
BUILDINGS BK /P/GJ
✓1 /
CONTRACTOR J t
ADDRESS CONNECTION DATA
CITY TEL NO STATION DEPTH
STATE UPPER
REGISTRATION NO COUNTY MANHOLE REFERENCE LOWER
NO DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y CURB PL ML TO P L 0
PUBLIC SEWER ® f5 00
SEFTIC TANK SEEPAGE PIT ORP C NO U
PITS AND/OR DRAINFIELD f10 00 CO IMP NO JOB NO
HOUSE:EWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO
PRIVATE DISPOSAL SYSTEM $300
CONNECT ADDITIONAL BLDG OR AFFIDAVIT WAILER I EIIEEYEIIT I RECORD INSTR NO DATE
WORK TO HOUSE SEWER N $300 E
OVERFLOW SEEPAGE PIT DRAINFIELD U)
EXTN CESSPOOL DRYWELL MANHOLE! 65 DO Z
ABANDON HOUSE HWY OR ST WIDENING
SEWE SYSTEM $300 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
OWNER'S PERMIT s 21 00 CHARGEE
AUTHORIZATION I TOTAL FEE CONNECTION CHARGE FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER APPROVALS DATE INSPECTOR 8 SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION SEPTIC TANK SEEP PIT(8)
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY AND/OR DRAINFIELD
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLU MBIN6 AND SEWERS CESSPOOL ❑ DRYWELL [3
1HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT 1 ON THE LEGAL OWNER OF AND INTEND TO DISCONNECT PLUG AND Pi
RESIDE IN TH ESCRIBED ESIDENTIAL PROPERTY ABANDON NOOSE SEWER
SIGNATURE
BACKFILL SEPTIC TANKS [3
BEEP PIT(S) ❑ CESSPOOLS
VALMATIO ROBERT A WOOD
CK M O CASH Prfn SUPERVISING MECHANICAL ENGINEER
LACa4 11510 D_ 5.00-
,. y w
DEPARTMENT OF OOUNTY rower amR SEWER-SEWAGE DISPOSAL 1
DIVISION OF BUnMING AND SAFETY PERMIT APPLICATION
DOIINTY OF LO$ "Gin"
BILDING
WILLIAM J. FOX, COUNTY ENGINEER ADDRESS ! J!�9,0' tjf.Z _
FOR
APPLICANT TO RLL IN LOCALITY pljo
r�
ADDRESSCR08SST.ST Lli�.r�.
LOCALITY G DISTRICT NO. SERIAL NO. PERMIT NO. c
CREAREOSS,ST 0^ A /..7
' $
Z "
RECEIVED BY Ready for Inspection DATE ISSUED
OWNER ed 4 3-s:3
MAIL USE ZONE OCCUPANCY BK MAP PO
ADDRESS d P,
CITY TEL.NO. ��
CONTRALTO
CO.IMP.NO
ADDRESS o. '_
JOB.N0.
CITY TEL.NO. T _ TRUNK PERMIT NO.
REGISTRATION NO STA
COUNTY
ROAD PERMIT NO
LEGAL ��z A STATE ENCROACHMENT
DESCRIPTION LOT NO /s( 4.44 Yp tt;4p-i PERMIT NO
,q4L� r "��,��5 ~ INDUSTRIAL
BLOCK TRACT (?
WASTE APPROVAL
SIZE OF LOT NOW ON LOTS CHARGES
USE OF CONNECTION CHARGE FEE
BUILDINGS
NO DESCRIPTION OF WORK FEE REIMBURSEMENT FEE
HOUSE$EWER CONNECTING TO
PUBLIC SEWER 0 = 880 RECEIPT NO DATE ISY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 100
CONNECT ADDITIONAL BLDG OR EXCEPTION RECORDED
WORK TO HOUSE SEWER 1 00 NO
ALTER OR REPAIR EXISTING - DAf BY
SEWER OR DISPOSAL SYSTEM 100
AMD/OR DISPOSAL AND ABANDON
SEWER 1 00 CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR GRAINFIELD 2.00 STATION �►" • DEPTH 6
CESSPOOL—DRYWELL `�-
SPECIAL CONDITIONS ONLY " 200 �t 7c Y NUP ER EFEERENCE
v
LL..rTME OFC ON NP.Lr� L L TO P L FROM 5t-,p
�
OWNERS PERMIT ; I 1 00
AUTHORIZATION TOTAL FEE
1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
HAVE
TO CONNECT THE ABOVE DESCRIBED EXISTING
APPROVALS INSPECTOR'! NATURE DATE
DWELLING TO THE PUBLIC SEWER
SIGNED THIS --DAY OF-.. ' _19 J3 NEW HOUSE SEWER. /8s3
OWNEROR �8�. CONNECT ADDITIONAL
S BUILDING OR WORK
OWNERS AGENT / /s �- SEPTIC TANK SEEP.PITS)
ADDRESS - - "+ - AND/OR GRAINFIELD
1 HEREBY ACKNOWLEDGE THAVI HAVE READ THIS APPLI- CESSPOOL DRYWELL 0
CAT
IONAND 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 DISPOUL8YSTEM '1
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED DISCONNECT PLUG AND
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COON
AND,
ND STATE OF CALIFORNIA OR THAT 1 THE LEGAL 0 ABANDON HOUSESEWER
ER OF THE ABOVE DE IBE E TIAL PROPERTY. BACKFILL SEPTIC TANKS[]
SIGNATURE SEEP PIT(S)[] CESSPOOLS o
OF PERMITTEE _
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