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K•66663 12.54 APPLICATION FOR ■ EF�MIT 1.
E -
DIVISION OF BUILDING AND SAFETY SEWER--SEWAGE DISPOSAL
Department of County Engineer
County of Los Angeles auILDING
WM.J. FOX, COUNTY ENGINEER ADDRESS ,y d /� �'i' + (',. '-
CASSATT D.GRIFFIN,SUPT OR BUILDING LOCALITY
FOR APPLICANTT2 FILL INJceoss sT;
LEGAL
QESCRIPTION LOT NO.. j X14 OWNER "
BLOCK TRACT w �j p)/7 ] �j J4 Y k MAIL d�
T -u�. —1 cr x ADDRESS
OF SLOGS.
SIZE OF L,OTedr„ P:O'nH_ON LOS_ . CITY 7EL. NO.
USE OF '— ...� ,
BUILDINGS strs' ee .�°¢ f�' DISTRICT NO.. GROUP.- i MAP
SK PG
CONTRACTOR ^♦ ,� t
ADDRESS �''-� - y CONNECTION DATA
CITY }- TEL, NO.A ° 4'z - STATION _...P DEPTH
O STATE MAN<'^- prP'EtEMrE
RECISTP.ATION NO. yCOUNTY f�. ' -` .;UPPc.R
-- TYPE 0,. c' yv aECTICN T L.ENCTH FROM
NO. DESCRIPTION OF WORK FEEY. r(�C URB = P_L �M.L TO P.
HU USE SrWbR CONNECmiNG TO - - J
PUBLIC SEWER_ t:trl $_ 3.50_I ---------_
—
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00 ! ----- ----- --�--• -- 19
CONNECT ADDITIONAL.BLQG. OR { CO. IMP. NO fJOB. N0.
WORK TO HOUSE SEWER 100 1 _ .__.._,...__. _ II
ALTER OR REPAIR EXISTING i^
SEWER OR DISPOSAL SYSTEM_ 1.00 TRUNK PERMIT NO. ROAD PERMIT NO `
DISCONNECT AND ABANDON SEWER
.00
AND/OR DISPOSAL SYSTEM 1,00 STATE ENCROACHMENT
PERMIT NO.
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/ R DP.AINFIELD2.00 INDUSTRIAL
CESSPOOL•DRYWELL-._ -- WASTE APPROVAL
SP!:CIAL CONDITIONS ONLY 2.00
CHARGES
CONNECTION CHARGE FEE —
OWNER'S PERMIT S g 1 i OD
AUTHORIZATION `TOTAL FEE �I )<. REIMVURSE67ENTFE_E_
1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED CON• APPROVALS ➢!7E INSPECTOR'S
TRACTOR TO CONNECT THE, ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER NEW HOUSE SEWER - —
SIGNED THIS DAY OF--.19--
OWNER
F— .19—_OWNER ORCONNECT ADDITIONAL
OW PIERS AG.�Q.Ta "j�V-�" �!? `'..' _ BUILDING OR WORK�,- ---
ADORESS ✓..t✓ /4' �"✓' - �...._— `ERIK TANK,SEEP.P17(5)
ND,'OR DRATPeFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL 0
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY ...�WITH ALL. COUNTY ORDINANCES AND SPATE LAWS REGULATING ALTER, REPAIR,SEWER OR
PLUMBiNG AND SEWER$. SEWAGE DISPOSAL SYSTEM _
IHEREBY CERTIFY THAT I AM PROPERLY RECISTERED AND/OR AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE DISCONNECT PLUG AND
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE _ _---.• .-
DESCRIBED RESIDENTIAL_PROPERTY. BACKFILL SEPTIC TANKS C) I
SEEP.PIT(S) 0 CESSPOOLS
5IGNATURti i
OF PERMITTEE - i4
WILLIAM J. FOX—COUNTY ENGINEER VALIDATION
By BY
DEPUTY DEPUTY
BY BY
Q) DEPUTY DEPUTY