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76A6442D 6..60 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL ,y �.
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIIVISION ]_7UILDING
IC7FIN A. LAhfBlS, County Enq,frioer ADDRESS
WILLIAM A. JENSEN, Supt of Building _'LOCALITY.
NEAREST f' fJ' o j;
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL
DESCRIPTION LOT NO. F� OWNF_R ✓: � f
BLOCK TRACT , eA. MAIL q
ADDRESSNeo ILDA'S.
Y`
SI7E OF LOT NOW ON LOT CITY TEL. NO ° � �....�.
USE.OF
BUILDINGS, : ' DISTRICT NO. 'GROUP MAP PROyESS;I 'BY
SK PG
CONTRAC.TO "� ✓ ✓' "- - - _ -
ADDRESS fy r ~
CONNECTION DATA
E _"� L DEPTH
CITYr�.>:'~.,..,. _ .d-:.,...aE' L,N0. STATION j
v STATE MANHOLE REFERENCE -!TIPPER
REGiyT'RATIOPd N0. __ �.. COUNTY
NO. I.^ DESCR'iPTION OFF WORK FE.'a�
HOliSE SFW P C'ON P.E.CCI N TO
$3..00 -
- TYPE OF CONNECTION... LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR Y. CURB P I- M.L.T
FITS AND OR DRAINFIELD t $3.00
OVERFLOW SEEPAGE PFI
..T,DRAINELD _
EXTN_ CESS 00' DRYYV_(.L. '+ $2.00
'iOUSE SEWER'01U'l C `NG TO P.C.N0.
YRIVA 1!DISPO5A. SY fEM a S5t.00 CO, IMP.NO, �j' JOB NO..
- F4
j WGTCONNECT OUSE W.^NA! trLDG.OR �' TRULIK PERMIT NO.5 .ROAD PERM5ITRO> 0
SVOR�TD Hf S -Sf WIR (1 .$'1.00
AtT �., RE-AUR OR ABANDON HOUSE STA"E ENCROACHMENT Al
5?:V�et;.M ORDR F r5. u;AYSTE.M C. S7,00 °CRMI i NO-. O
{ iNDUSTRiAL - G
WASTE APPROVAL_,_.- - - 41
CHARGES rf]
OWNER'OWNER's PERMIT $.I{ 2 , 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE 1 24!fREIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WI1'H THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS TE INSPFCTOR'SSIGNATURE
TO THE PUELIC SEWER.
SIGNED THIS " !DAY O°_ 19� NEW HOUSE SEWER _
�-� CONNECT ADDITIONAL
OWNERS AGE- - BUILDING ORWORK
.
ADDRESS._ -_. SEPTIC TANK.,SEEP.PIT(S)
--- -- — AND/OR DRAINFIELD
L 1-ff-Ar Y ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT `7-HE ABOVE IS CORRECT AND AGREE TO COMPLY _CESSPOOL (0 DRYW£LL El
V!t'FH ALI. COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER:REPAIR,SEWER OR
PL:iMBiNG AND SEWERS. SEWAGE DISPOSAL WESTER
I HERESY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/0;•1 _DISCONNECT PLUG SYS i
LICEN$CD AS REQUIRED BY LOS ANGELES COUNTY AND STATE uF DISCONNECT
ABANDre HOUSE G AND
CA C.I.ORNIA OR THA. i AM HE LEGAL. OWNER OF THE ABOVE -
D 4+mRi8ED RESIDE ' L PROPERT'. - WER
BACKiILL SEPTIC TANKS
SIGNA URE '� �� ,,. SEEP. PIT(S) i�l CESSPOOLS
OF P ER MH I TE E
VALIDATION°- . ., ROBERT A. WOOD
Cr, W o. CASH SUPERVISING MECHANICAL, ENGINEER
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