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DEPARTMENT OF COUNTY ENGINEER i EWER-SEWAGE DISPOSAL 1
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER BUILDING
ADDRESS
" FOR APPLICANT Tq FILL IN NEARE Tv
BUILDING NEAREST
-
ADDRESS o CROSS ST. W
LOCALITY C L a DISTRICT SERIAL N0. PERMIT N0.
NEAREST_ < A A R—/��/q-- c
CROSS ST. ) -- jj
RE IVED BY Ready for Inapec Ion DATE ISSUED
OWNER ,� ;;I -'� -.
MAIL °'" USE E OCCUPANCY MAP
ADDRESS '7 k, 4-j G:rr.�
SK PG
CITY -_6 TEL.NO. �"'
CONTRACTOR
t`" f }�i' CO.IMP.NO.
ADDRESS kHera 10B NO.
CITY A c r i t TEL.NO. � ,-'-'A/
TRUNK PERMIT NO.
REGISTRATION NO. A2 COUNTY ROAD PERMIT NO.
LEGAL
DESCRIPTION LOT NO. ,�'� STATE ENCROACHMENT
c i.✓ PERMIT NO.
BLOCK TRACTS-41r'f }-�/v t i�L J�rp -� INDUSTRIAL
WASTE APPROVAL
SIZE OF LOT N0.OF BL
NOW ON LOTH GES
USE OF
BUILDINGS` +cl: �.�: '- CONNECTION CHARGE F
NO.j DESCRIPTION OF WORK FEE d
HOUSE SEWERCONNECTING TO REIMBURSEMENT FFA
PUBLIC SEWER @ $ 3.50RECEIPT NO ( DATE I BY
HDUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM t.00
CONNECT ADDITIONAL BLDG.OR EXCEPTION RECORDED
WORK TO HOUSE SEWER 1.00
ALTER 8R REPAIR EXISTING NO- DATE BY
SEWER OR DISPOSAL SYSTEM 1.00
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1.00 CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR ry
PITS AND/OR DRAINFIELD 2.00 STATION A� �—. DEPTH
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 2.00 MANHOLE REFERENCEw6mi
_,+- UPPER
TYPE OF CONNECTION LENGTH FROM
OWNERS PERMIT $ 1 OO Y. ARffiz ML.TO P.L.
AUTHORIZATION I TOTAL FEE
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING
DWELLING TO THE PUBLIC SEWER APPROVALS 1NSPECTOR'SSIGNATURE DATE
SIGNED THIS--- _. ---DAY OF - t. NEW HOUSE SEWER
�t
CONNECT ADDITION
ALOWNER BUILDING OR WORK
SEPTIC TANK,SEEP.PI
T(S)OWNERS .....
ADDRESS........ .
_ _.....
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI- CESSPOOL[] DRYWELL W
CA
TIONAND 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
1 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 CALI ORNIA OR THAT 1 AM THE LEGAL OWN- _
ER OF THE ABOVE,. ESSCyR,IBED RESIDE TIAL RR�� OPE TY. BACKFILL SEPTIC TANKS
OF PERMITTEE.._ '�' r' `y SEEP.PIT(S)� CESSPOOLS
SIGNATURE '
76A6A2D 663 1/53