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DEPARTMENT OF COUNTY ENGUIRM s —SEWAGE DISPOSAL
bIVMION OF 13UnMING AND SAFETY , APPLICATION 9441
e COUNTY OF LOS "GZLM
WILLIAM J FOX. COUNTY ENGINEER ADDRE G I
2
' FOR�APPLINT TOFILL IN LooALITY
DING
BUDRESSLJl 9— L 2 NEAREST
ADDRESS t/%Z '7. J
LOCALITY DISTRICT'NO SERIAL NO PERMIT NO
NEAREST J A C 3 S
CROSR STAla
C ED Y Ready for laepeetleo DATE ISSUED
OWNERJJ
MAIL
ADDRESS USE ZONE OCCUPANCY BK MAP PO
CITY _ TEL NO /
CONTRAHTOR California SA s.._.R CO IMP NO I*
ADDRESS / 1317 Colegrove A*Q, JOB NO
CITY IlOa'tobello TEL NO TRUNK PERMIT NO
REGIST ION NO 104445tin
C NTY ROAD PERMIT NO �!
DESCRIPTION LOT NO 3a /n I s(a 1p STATE ENCROACHMENT
PERMIT NO
BLOCK TRACT �� INDUSTRIAL "rte
WASTE APPROVAL
SIZE OF LOTS"&_j a NOW ON LOTS CHARGES
USE OF
BUILDINGS CONNECTION CHARS FEE
NO DESCRIPTION OF WORK FEE REIMBURSEMENT FEE
NOOSE SEWER CONNECTING TO
PUBLIC SEWER ell 350 RECEIPT NO DATE BY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 100
CONNECT ADDITIONAL BLDG OR EXCEPTION R RDED
WORK TO HOUSE SEWER 100
ALTER OR REPAIR EXISTING NO ATE BY
SEWER OR DISPOSAL SYSTEM too
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 100 CON CTION DATA
SEPTIC TANK SEEPAGE PIT OR
PITS AND/ORDRAINFIELD 200 STATION D DEPTH
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 200 9� MANHOLE REFERENCE UPPER W LOWER
TYPE OF CONNECTIqAr•� LENGTH FROM /
OWNERS PERMIT $ 1 00 r! cels LP 0 ML TO P L y
AUTHORIZATION TOTAL FEE
1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTORS SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER
SIGNED THIS -RAY OF _19 NEW HOUSE SEWER -
OWNER OR _ _ �Lr--e.
BUNLDINO OR WORKAL
OWNERS AGENT �s�ADDRE88 �i�_ alk+l AND�OR DRAINFIELD PIT(S)
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI CESSPOOL 0 DRYWELL
CATION AND 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 I AM PROPERLY REGISTERED DISCONNECT PLUG AND
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOUSE SEWER
AND STATE OF CALIFORNIA OR THAT 1 AM THE LEGAL OWN
ER OF THE ABOVE DESCRI D RE DENTIAL PROPERTY BACKFILL SEPTIC TANKS
SEEP PIT(S)[] CESSPOOLS� i
SIGNATURE
OF PERMITTEE J
TUS42D SOS 1/85