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DEPASTAKEAiT OF OOUNTY ENGENEM SEWER-SEWAGE DISPOSAL 1
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COU14W OF L08 ANGELES
WILLIAM J FOX, COUNTY ENGINEER BUD
ILDING 73 O
ADDRESS
FOR APPLICANT TO-RLL IN LOCALITY
BUILDING NEAREST
ADDRESS CROSS 8T L
LOCALITY , DISTRICT NO SERIAL NO PERMIT NO
CROSS ST �.' {, Qom" A ' S
RECEIV9j8X Readylw InspnUoa DAT ISSUE
OWNER D
MAIL
ADDRESS E ZO OCCUPANCY BIC
AIS oV
CI EL N 1 l K` a7 �s G !'C
CONTRACTOR CO IMP MO
ADDRESS
ONO
CITY1960-Alt-
STATE TRUNK PERMIT NO
REGISTRATION NO S Z e OY ROAD PERMIT NO !�s
LEGAL 22
DESCRIPTION LOT NO jt STATE ENCROACHMENT
PERMIT NO
BLOCK TRACT Gi / INDUSTRIAL
�[�^ ~ NO BF BLDOS WASTE APPROVAL
SIZE OF LOT J NOW ON LOT CHARGES
BUILDINGS, CONNECTION CHARD FEE
MO DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO REIMBURSEMENT FEE
PUBLIC SEWER ell 0.00 RECEIPT NODATE BY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 100
CONNECT ADDITIONAL OLDS OR EXCE ON RECORDED
WORK TO HOUSE SEWER 100
ALTER OR REPAIR EXISTING NO DATE BY
SEWER OR DISPOSAL SYSTEM 100
AND OR DISPOSAL SYSTEM SEWER 100
CONNECTION DATA
SEPTIC TANK SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 2AO STATION DEPTH
CESSPOOL-DRYWELLtic
SPECIAL CONDITIONS ONLY 200 ♦ MANANOPI,LWERREFERENCE LOW
TYPEOF/UVB CTIO�� M L TO P FROM
m
OWNERS PERMIT ¢ 1 oO
z—t4
AUTHORIZATION TOTAL FEE
1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR 8 SIGNATURE DATE
DWELLING TO TH/E/PUBLIC SEWER
ift-
SIGNED THIS DAY OF _ _s 190 NEW HOUSE SEWER � p
OWNER OR CONNECT ADDITIONAL
OWNERS AGEP -3- -
_ _ _ j(�L� BUILDING OR WORK
ADDRESS �Y-+.i AND/OR GRAIEPTICTANK NFIELD
ELEEPD IT(8)
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLI CESSPOOL[] DRYWELL I]
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
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED DISCONNECT PLUG AND
AND/OR LICENSED AS REQUIRED BY LOS A S COUNTY
AND STATE OF CALIFORNIA OR THAT 1 %E LEGAL O N ABANDON HOUSE SEWER
ER OF THE ABOVE DESCRIBED RESID AL PROPERTY BACKFILL SEPTIC TANKS01 �''77
SIGNATURE SEEP PIT($)[] CESSPOOLS
OF PERMITTEE _
70A048D 603 1/60 - d