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E-663 mss APPLICATION FOR PERMIT 1
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DIVISION OF BUILDING AND SAFETY SEWER--SEWAGE DISPOSAL
Department of County Engineer
County of Los Angeles 3utLDTNGI
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JOHN A. LAMt31E, COUNTY ENGINEER --
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CASSA7T D. GRIFFIN; SUP'T Or BUILDING LOCALITY
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FO APPLICANT TO FILL IN cess S .
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DESCRIPTION LOT N _ OWNER„ tJ s ' y'y
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BLOCK TRACT f/j+'_�- _"tDDR - ; �+ ` ;[ ..'' .✓&_.y..r
NO. OF BLDG$. ' TEL. N0.
SIZE OF LOT �. NOW ON LOT CITY
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USE OF 9 DISTRICT N0, GROUP MAP
BUILDINGS 'y>''-'
- - - - BK PG
CONTRAC'T'OR
ADDRESS ' _ ___ CONNECTION DATA
_STATION �S �`- t�.,L 7DEPTH
CITY /' -� L. N cf- .,�° MANHOLE REFERENCE UPPER
- f F STATE ------ d=� 4 w �•_
..REGISTRATION N0. SAF 3' ,ad �' ❑ COUNTS' - - —
Na. DESCRIPI[ON OF WORK- F` i ---
HOUSE EWER CONNECTING TO TYPE OF Gf3stixy�CTION LENGTH FROM
PUBLIC SEWER I Y• "°CURB P.L. M.L.TO P.L. ..,_
SFPTIC TANK,SEEPAGE PIT OR
FIT$AND/OR DRAINFIELD _ _C $3.00
OVERFLOW SEEPAGE P'7 DRAtNFIELD P C. NO.
{ EkTN-CESS POOL,DRYWELL,MAN110LE !a� $ 2.00 CO. IMP. N0. ,r y € -.__.JOB NO.
HOUSE SEWER CONNEC T ING TO
PRIVATE
DISPOSAL SYSTEM Gt $.1.00 I� TRUNK PERMIT NO. - ROAD PERMIT NO:
CONNECT ADW IGNALBLDC OR STATE ENCROACHMENT
WORIr TO H9USE SEWER �u $1.00 I_r �L"% PERM_[T NU ______
I ALTER,REPAIR,OR ABANDON HOUSE t I
SEWER OR DISPOSAL SYSTEM (i $1.pn F _ INDUSTRIAL
--- -- -_-- __--. WASTE APPROVAL
CHARGES
.----- CONNECTION CHARGE FEE
$ [ DQ -
OWNER°S PERMIT --- --- -- --- -- _—:_� —
�
[TOTAL
REIMBURSEMENT FEE
AUTHORIZATION FEE —
I HAVE AT THIS DATE A CONTRACTAPPROVALS i DATE INSPECTORS SIGNATURE
. WITH THE HEREIN NAMED CON- _—_�—._.__ __ _�__._L___
TRACTOR TO CONNECT THE ABOVE DESCRiBF.D/EYISTiNG DWELLING
TO THE PUBLIC Sp' ER r'd'' - NEW MOUSE SEWER
DAY
SIGNED THIS i Or
' CONNECT ADDITIONAL -
OWN.E4 OR P,
,.� BUILDING OR WOK_
OWNERS AGF�N'I" --- ---- -- Ij
• " c I -! C,> SEPTIC TANK,SEEP,.PITiSi 1 -
ADDRLSS ' -:-- - �.}'_' .1.- _Y`� AICD/OR DRAINFIELD
7 Hc.P+=BY ACKN YVLEDC,E THAT f HAVE READ TY.15 APPLICAT
AND STATE TliAT THE ABOVE 1S CORRECT AND AGREE TO COMPLY CESSPOOL U DRYWE.LL
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR j
PLUMBING A14D SEWERS, SEWAGE DISPOSAL SYSTEM
1 HERESY CERTfFY THAT i AM PROPERLY REGISTERED A4DiOR DISCONNECT PLU AND
LICENSED AS REQUIRED BY LOS ANGELES CO41*TY ANC ST E OT• i I
CAL.fFC:F;NIA OR THAT I IAM THE LEGAL NER OF TH dABOVF ABANDON HOUSE SEWER
DESCRIBED RESIDENTIAL PR�� TY. ,.� P4. KFILL ;.-9`i"""",wrTa�."J'*L] -i. __._
,P ✓ CESSPOOLS LL', 7 r
SIGNATURE -- - - ----- -'-_ -----
OF PERMITTEE
JOHN A. LAMBIE, COUNTY ENGINEER VALIDATION ROBERT A.WOOD, CHIEF PLBG. INSPECTOR
CK. N.0. CASNA,