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S&E�Bff3 I?.D4 APPLICATION LICATIVN FOR PERMIT
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DIVISION OF BUILDING AND SAFM SEWER-SEWAGE DISPOSAL
DeparImenat of County Engineer
County of Los Angeles BUILDING
WM.J. FOX, COUNTY ENGINEER ADDRESS -
CASSATT D,GRIFFIN,SUPT OF BUILDING J_LOCALITY -
FOR'PPPLICANT TO FILL IN NEAREST
CROSS ST,
LEGAL : -
DESCRIPTION _LOT NO. ......._Y�.�....._ OWNER -
BLOCK TRACT MAIL
--.---------^ --.
_ADDRESS
NO.OF BLOGS.
NOW ON LOT G?TY TEL. NO.
USE OF _..
BUILDiNr9 DISTRICT FAD � GROUP_ i MAP
8K tG
CONTRACTOR J-
ADDRESS ... - CONNECTION DATA
CITY TEL., NO. STATION DEPTH
STATE _ MANun,.':-.REFE$ZENC£
REGISTRATION NO, J COUNTY IJPPCR': LOWER
-- --------- - TYPE OF,-taw{ECTION LENGTV FROM
URP.L. M.L.TO P.
;�, P
NO,! DESCRIPTION OF WORK FEE Y: {y � _
-HOUSE SE ER CONNECTING 70
_ PUBLIC SEWER (x r 3.50
HOUSE SEWER CONNECTING TO
j PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.OR �
I CO. IMP, NO. ' J06. N0.
WORK TO HO u_S E_°EWER __
_ � t -
.00 � i - _. .-
ALDER OR REPAIR EXISTING � ` .--... u3r
j SEWER OR DISPOSAL SYSTEM _ t.00 I TRUNK PERMIT N0. ROAD PERMIT NO.
t
DISCONNECT AND ABANDON SEWER
_ STATE ENCROACHMENT --
-AND/OR_DISPOSAL SYSTEM 1.00 I__�, PERMIT NO.
`.ISEPTIC TANK SEEPAGE PIT OR -_4I
PITS AND/OR DR,AiNFIELIDw.00 INDUSTRIAL - - -----
-+
CESSPOOL DRYWELL
-- "-- WASTE APPROVAL SPECIAL CONDITIONS ONLY -_2_0.0 � CHARGES
---PERMT --- CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE `--..I REIMBURSEMENT FETE
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED CON- APPROVALS DATE_ INSPECTOR'S SIGNATURE
TRACTOR TO CONNECT THE-AB�O�V,pESCRIBED EX€STIN2 DWELLING
TO THE FUBLIC-SEWZ_a '- --- —" -
SIGNED TH,Jt_ .__� pAy OF� p �r r� �g'y=- NEW HOUSE SEWER
OWNER �3R �"; ' "? ' CONNECT ADDITIONAL
-
C4VNERS AL�EHT` BUILDING OR WORK -
r r SEPTIC TANK. SEEP, PIT(S)
AND/OR DRAINF'IELD
1 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 STATE LAWS REGULATING ALTER, REPAIR,SEWER OR -
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND R
LICENSED AS REOUIRED BY LOS-ANGELES COUNTY AND STATE OF DISCON N HOPLUG AND
CALIFORNIA OR THAT t AM THE LEGAL O'NNEP OF THE ABOVE ._A D_ -._Y
DESCRIBED P =10ENTIAL PROPERTY, BACKFILL SEPTIC TANKS 0 ---
S€EP. PIT{S) ❑ C£95POOLS L,,._
SIGNATURE.. - - --
OF PERMI:iTE`a -
WILLIAM J. FOX,COUNTY ENGINEER VALIDATION
BY �D ' 'BY 7 ,'-"'
DEPUTY -DEPUTY
BY BY
4% DEPUTY c � DEPUTY