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'€A6420 APPLICATION FOR PERMIT
COUNT` OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER ���/�FZ--�� ��� �����S�L
BUILDING .AND SAFETY DIVISION
BUILD
IN
JOHN Aa LAMBIE, County Engineer E —
WILLIAM A. TENSEN, Sup'4 of BuildingST
FOR APPLICANT 0 FIIii ' T
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LEGAL
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BLOC f i RACT '-J ,': A DRE55""-�_:,v_- ._
NO. OF' BLDG S.
SIZE OF i_0Y NOW ON LOT. CITY TEL. NO,
USE O=
BUILMNGS DISTRICT NO- GROUP MAP PROCESSED B
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CONNECTION DATA
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AT]•Dh DEPTH +,
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' : MANHOLE RE"E'i2ENCE a f� d -- _
?REGISTRA ON- NO, .+ Y "f
; y - L' COUNT _ fi � _-LOWER
NU v SCRIPT.ON OF WORK FEE �. >
TYPE 6F ORNLC' ON r_EN TH FROM
HOUSE SE.Wr.RNNECTING TO Y_ CURB P L M.L.Y[.P.L. 0
FU£+LI .SEWE—A CO
S T LTANK 5 EF ACF h1T GR --- -- 1��--�- P.C.NO (�
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T AND ORVRAIN IEL.0 @ $lU OU O,IMP TJO _ A `; 6^i0
� HU SS. SEWER CONNECT NG TO'...—_. -.--
PRiVA*E DISPOSAL SYSTEM @ S3.D0 TRUNK PERM1T NO. ROAD PERMIT NO.
C ON NECr A-0-D-1 TIONAL BLpG OR - AFFIDAVIT wn;t_v EhS ASSYT RECORD.!.N STR.NO-TDATE
WOR O HOUSE SEWER @ $:_.OU I I �—_ _ iL
I
OVERFLOW SLEPAf L PIT,DRA PJ F!ELO
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EXTIV ,ESSP60L,pRY4NFLL:MRNF CLE 0 $5.00 ...
ALTER,REPAIR OR ABANDON HOUSE -_- —---
HWY.OR ST.WIDENINGG
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SE'WE'R tJS'OR DISPOSAL SYSTEM 53:00 _ STATE ENCROACHMENT
_.ERM,r NO.
__---_--__...-_. _.�__—._. -.__-_-_ INDUSTRIAL.
--- _ WASTE APPROVAL
®�G'N�LR`S I'FRIKIT 8 -- - -- ——— ---—--
CHARGES
2L9
-.__._.___...— . ___.___..__.-- CON.NE ION CHR RGE FEE
.AUTHORIZATION TOTAL FEE
HAVE AT THIS DATE. A CONYRACONTRACTWITH THE H&:RFI:1'r NAMED CCN-- >;E;MSURSEMENT FEE- ---- --
TRACTOR TO CONN EC- THE ABOVE DESCRI
TC THE PUBLIC SFW v 17��( }}yyy���yy�y 77(('� DATE INSPECTORS SIGNATURE
d]Pl'RV Y C1LS
SIGNED THIS_ - DAY Jh" - _i�' ;,t' - --
OWNER.OR .., NEW HOUSESEWEF7'
-- - ---
OWNERS AGENT,=f' ,�K _ -.� �G"l "M.. -- CONNECT ADO?T TONAL I .� 1
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BUILDING OR WORK
"ADDRESS.
E T'IL' TANK SEEP PIT(5) �.
1 HEREBYACKNOWLEDGE THAT HAVE READ THIS APPLICATION ANO/OR DRAINFIELD
AND _TATE THAT TETE ABOVE iS COR RE^_T AND AGREE TO COMPLY
WITH ALL. COUNTY ORDINANCES .AND STATE LAWS REGULATING J
C ES�,FOOL U DRYWELL
PLUMBING AND SEWERS.
1 HEREBY CFR FY THAT I AM PROPERLY REGISTERED AND i'OR ALTER,7. FAIR.SEWER OR -- _---- - -- ---�---
'iCENSED AS PEOUIREi,> 8 Y LOS ANGLES COUNTY AND STATE OF SEWAGE D PC�SAL SYSTEM
ALiF'OR NlA OR !^IAT y1'A Il9 HE t c.AL OWNER OF, 1NQ, YP•1TEPdD TO DISCONNECT LUG AND __-
R{_S,DE IN THE AB D .RI IAG RESIDENTIAL PRpnRTY ABANDON HOUSE EWER
v
IGNA URE + N r!- -- - _.}_—
OF e'ERT.!T'T P-_E ,- f 4; ss �a rTy g,:a BA KF'ILLSEP11c t] _
- 'Lf2.._ — SEE,-,PIT{S) LSI CESSPOOLS Q
VALIDATION ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
CK. M.O. L "ASH _