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DEPARTMENT OF COUNTY ENGn1TEER SEWER-SEWAGE DISPOSAL 19191
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION �(
COUNTY OF LOS ANGELES S S ^,�j '':Y✓
WILLIAM J FOX, COUNTY ENGINEER BUILDING
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FOR APPLI NT T FILL IN
LOCALITY
BUILDINO1/1 9_ Q - NEAREST
ADDRESS ((��0� O CROSS ST
LOCALITY DISTRICT NO SERIAL NO PERMIT NO
NEAREST S A /003 ?, S
CROSS ST
f REC IVED BY Ready for leepeetioe DATE IS8U�ED�{
OWNER /L // 3 - "�,
MAIL USE ZONE OCCUPANCYMAP PQ
ADBRE
CITY L TELROI �L
CONTRACTOR Callforma So~ C�it•RO CO IMP NO �
ADDRESS - I Colegrove Ave. JOB NO
CITY lLntebello TEL NO UNlon 15048 TRUNK PERMIT NO
REGISTRATION NO 104445 S®eNgTEr
ROAD PERMIT NO
LEGAL -
DESCRIPTION LOT NO PERMIT ENCROACHMENT
BLOCK TRACT, 3 7 INDUSTRIAL
WASTE APPROVAL --�
SIZE OF LOT D NOW ON LOTS
CHARGES
138E OF
BUILDINGS CONNECTION CHARGE FEE
NO DESCRIPTION OF WORK FEE REIMBURSEMENT
PUBLIC SEWER CONNECTING TO ! $ 880
D RECEIPT NO TE BY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 100
CONNECT ADDITIONAL BLDG OR CEPTION CORDED
WORK TO HOUSE SEWER 100
ALTER OR REPAIR EXISTING DAT SY
HEWER OR DISPOSAL SYSTEM 100
DISCONNECT
ND%OR DISPOSAL SY8TEN SEWER 100 CONNECTION DATA
SEPTIC TANK SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 200 STATION f' �� DEPTH
SPECIAL CCOONDIITIONS ONLY 200O / M9NIHOLEERREFERENCE
tmMwB
TYPE OF CONNEC O LENGTH FROM /
OWNERS PERMIT ; 1 00 �— a P L M L TO P L 5
AUTHORIZATION I TOTAL FEE z)
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR S SIGNATURE DATE
DWELLING TO THE PUB IC SEWER r
SIGNED THIS Y OF 9__L NEW HOUSE SEWER sek YDG
OWNER OR CONNECT ADDITIONAL
OWNERS AGEN BUILDING OR WORK
SEPTIC TANK SEEP PIT(S)
ADDRESS D ►. r1 AND/OR DRAINFIELD
I HEREBY ACK LEDGE THAT 1 HAVE READ THIS APPLI CESSPOOL E3 DRYWELL❑
CATION AND STATE THAT THE ABOVE 18 CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER REPAIR SEWER OR
REGULATING PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND
DISCONNECT PLUG
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOPLUGAND
AND STATE OF CALIFORNIA OR THAT 1 AM THE LEGAL OWN
ER OF THE ABOVE DESCRIBE RESIDENTIAL PROPERTY BACKFILL SEPTIC TANKS 13
SIGNATURE
SEEP PIT(8)o CESSPOOLS
c
OF PERMITTEE _Is
7GA642A 663 7/53