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DEPARTMENT OF COUNTY ENGlNEnER SEWER—SEWAGE DISPOSAL
` DIVISION OF BUILDING AND SAFETY3 4 1 5 1
COUNTY OF LOS ANGELES PERMIT APPLICATION
WILLIAM J. FOX, COUNTY ENGINEER "I BUILDING �� C� ��
a ADDRESS "y A" T ' 1�r A a
FOR APPLICANT TO F L IN LOCALITY
BUILDING ! NEAREST
ADDRESS _ .L CROSS ST.
LOCALITY DISTRICT NO. SERIAL NO. PERMIT NO.
NEAREST A �j 7 g rj y S
CROSS ST.
,y 7CVEQEJBYReady for Inspection DATEISSUED
OWNER t..0,-VY V(6 (w f°�Ll
MAILUSE kbNE OCCUPANCY 0` " ' � * BK MAP PG
ADDRESS j .4,r�,/�,,A� __
CITYTEL.NO. 17'-
CONTRACTOR, � ' _`�DI'ula Sewer Const.CO..
CO.IMr.NO. /
ADDRESS v_ _EL'rcyE) .Ave.
JOB NB.
CITY i =ilc,be 110 TEL.NQjjon ..5048
_ pp TRUNK PERMI"O.
REGISTRATIONN0�-4�5r .Site QOU TY ROADPERMITNO.F
LEGAL
DESCRIPTION LOT NO. 7- STATE ENCROACHMENT
PERMIT NO. gyp_ r!r I„/
BLOCKJO TRACT INDUSTRIAL
WASTE APPROVAL
SIZE OF LOTS /� NO.OF BLOCS.
V :NOW ON LOT CHARGES
USE OF -elf
BUILDINGS _ CONNECTION MARGE FEE ®�
NO. DESCRIPTION OF,WORK FEE ®�
HOUSE SEWER CONNECTING TOS.
REIMBURPEMENT FEE
I PUBLIC SEWER - 0 $ 6.30 t'1 t RECEIPT NO. I DATE I BY
HOUSE.SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
CONVECT ADDITIONAL BLDG.OR EXCEPTION RECORDED
WORK TO HOUSE SEWER _ 1.00
ALTER OR REPAIR EXISTING NO. I DATE 113Y
SEWER OR DISPOSAL SYSTEM 1.00
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1.00 CONNECTION DATA
SEPTIC TANK.SEEPAGE PIT OR
PITS AND/OR GRAINFIELD 2.00 STATION DEPTH
CESSPOOL—D RY W ELL
SPECIAL CONDITIONS ONLY 2.00 0/ `/ o NPP R FERENCE
TYPE OF CONNECTIONNGTH FROM /
OWNERS PERMIT S. 1 GO Y. CURB P.L. M.L.TO P.L.
AUTHORIZATION I TOTAL FEE
I HAVE THIS DATE CONTRACTED WITH THE HEREI NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING_ _ APPROVALS - lNSPECTOR'SSIGNATURE DATE
DWELLING TO THE BLIC SEWER
SIGNED THIS-21. DAY OF.... OUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGEN �.// .. ._. ./..... .. _ .__ BUILDING OR WORK
ADDRESS_..... .. ._. PTIC TANK.8EEP.'PIT(S)
_ _............._...._...---....._....-•-- D/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ TJAGREE
CESSPOOL[] DRYWELL E
CATION AND STATE THAT THE ABOVE IS'CORRECT ANDTO.COMPLYWITH ALL COUNTY ORDINANCESAND SALTER,REPAIR.SEWER OR
REGULATING PyLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
1HEREBY 6ERTIFY THAT I AM PROPERLY DISCOgNECT PLUG AND
AND/OR LICENSED.AS REQUIRED BY LOS ANGELABANDON HOUSE SEWERAND STATE OF CALIFORNIA OR THAT I AM THE L -
ER OF THE ABOVE DESC ISE RESIDENTIAL PROBACKFILL SEPTIC TANKS
SIGNATURE / SEEP.PIT(S)[] CESSPOOLS
OF PERMITTEE. _
76A642D 663 1/36 'f