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cEe08 11-57 APPLICATION FOR PERMIT/:� '/
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAM County Engineer ADDRESS .1 s::-e Stre.et
CASSATT D. GRIFFIN, Supt of Building ::!emr_1e City
LOCALITY I
NEAREST e Cak
FOR APPLICANT TO FILL IN CROSS ST.
NG t
BUILDING
ADDRESS
LOCALITY
_�e
LEGAL
DESCRIPTION LOT NO.
OWNER vl J. "I U0
- U c
�' 6
MAIL'L ,Zwsa 1_-Loo.
1
BLOCK TRACT ADDRESS
NO.OF BLDGS. TEL.NO. Gi. 3 UC7
SIZE OF LOT NOW ON LOT CITY e
USE OF T_�15 en BUII-DINGS DISTRICT N% GROUP MAP
c
CONTRACTOR
-5,7
ADDRrss 13-Ox -08 CONNECTION DATA
CITY NO.
STATION /� DEPTH
IV t� 0- z
i,yMANHOLE REFERENCE
bl", STATE
REGISTRATION NO. COUNTY ? UPPER
N11- 1_DESCRIPTION OF WORK FEE
4 SEWER CONNECTING TO
PUBLIC SEWER CIO
H, @ $3.00 3 "�'___
SEPTIC TANK,SEEPAGE PIT OR TYPE OF CONNECTIDf LENGTH FROM
Y. CURB F.L. M.L�TO P.L.
PITS AND/OR DRAI NFIELD
OVERFLOW SEEPAGE PIT, DRAINFIELD
EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $2.00
HOUSE SEWER CONNECTING TO P.C, NO.
PRIVATE DISPOSAL SYSTEM q $1.00 CO. IMP.NO. JOB NO.
CCNNEcr ADDITIONAL BLDG.OR
--WORK TO HOUSE SEWER @ $1.00 TRUNK PERMIT NO. ROAD PERMIT NO.
ALTER,REPAIR 5R ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM @ $1.00 STATE ENCROACHMENT
__PERMITNO,
INDUSTRIAL
WASTE APPROVAL
CHARGES
Obi ER'S j_PERMIT Y
00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE 00 REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON.
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPEcTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS— DAY OF—---I 9— NEW HOUSE SEWER
OWNER OR e u CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADDRESS- SEPTIC TANK,SEEP,PIT(S)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL[] DRYWrLL 0
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. ALTER,REPAIR,SEWER OR
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR _SEWAGE DISPOSAL SYSTEM
LICENSED AS REQUIRED BY LOS tNGELES COUNTY AND STATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT I AM .-TIQ LEGAL OWNER OF THE ABOVE _L8—Af�DON-HOUSE LSEWER
DESCRIBED RESIDE PRO'ftlljr. BACKFILL SEPTIC TANKS El, I
SIGNATURE SEEP.PITS? [71 CESSPOOLS 0 1
-
OF PERMITTEE
VALIDATION ROBERT A. WOOD
CKM.0. CASH SUPERVISING MECHANICAL ENGINEER