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SIGNED THI Y F 1 NEW HOUSE @EWES
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IIEGULATINO PLUMBING AND BEWERL BEWAGE DI @Y@TEM
1 HEREBY OERTIFpY� THAT 1 AM PROPERLY REGIBTENED
ANI/OR LICENSED AS REQUIRED BY LOS ANGELESOOUMTY'
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76A642I9 APPLICATION FOR PERMIT 1
a.3.1o�669 9!.55
DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL
Department of County Engineer
County of Los Angeles BUILDING - �1 s_.'I .Eo �
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JOHN A.LAtvSBlE.±voU>�a'Ie�
" ENGINEER -- --,
CASS.ATT O. GRIFFIN, SUPT 0F�8u1LDINc —ADDRESS 1. a
LOCALITY 1p ra:tyn 3T r
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL
DESCRIPTION LOT NO ��Aa tCg� OWNER Frank '5`a� ta'��`Y� (Cont!'B tali,
ttgs
+ MAIL
BLOCK TRACT
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NO.OF BLDG$.
IE �-
SIOF LUT tr SNOW ON LOT CITY ,r`""'_.N + TEL. NO.
USE OF
BUILDINGS .—Residence � DISTRICT NO. GROUP � BK MAP PG
CONTRACTOR I? .ler :S'l .t`�.S�ii ,��, '�S�`'s�'�6
AD RE — a r' -_—_^_ __ CONNECTION
�y y' STATION DEPTH
CITYk TEL.Na. o.,7 -46 - ---- - --- P
�-- �--- MANHOLE REFERENCE U.PER
STATE LOWER
Er;7
-_STRATION NO. 1 a"`t,>d rt COUNTY
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NO DESCRIPTION OF WORK FEE
_ - - 0CONNECTION
HOUSE SE EST CONNE'T-NC TO I � TYPE F M.L. Tk FROM
PUBLIC EWER @ g Y• CURB P.L.. M.L.TO P,L.
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If SEP IrTPNn -E£PAtc UITOR F
PITS AND/OR 6RA[NFitLD $3,D
CtiERF..O SEEPAGEPIT,DRAiNFIELD ` - P. C. NO, —
EXTN CES FOOLDRY1 ZLL,MANHOLF I) $2.001 CO imp. NG-.
HOU-S-E SEWER CONNECTING TL% -
PRIVATE WSPCSAL SYSTEM < $ K-�-- TRUNPERMIT NO. ROAD.16 -IT NO.
CONNECT
ADDITIONAL BLDG. ST
OR - - ---- ENCROACHMENT--- --
ATE
WORK TO HOUSE SEWER in b 1,UC j` PERMI T N0. _-._—_ - --' ---
ALTER,REPAIR OR ABANDON HOUSE ---- - ---- �_
INDUSTRIAL
SEWER OR DEPOSAL SYSTEM WASTE APPROVAL
I
CHARGES
CONNFUTON CHARGE F6£ -
OWNER'S PI:RMlT _r ---- __---------
- REIMBURSEMENT FEE -
AUTHORIZATION TOTAL IEE �T Y APPROVALS DA7C j!NSPE TORS;IGPeATU,2E
t
HAVE AT - '1L- DATE A COkTRAtT WITH THE HEREIN NAMED CON- ----
TRACTOR CO CONNECT THE ABCIVE DESCR'BED Ek ST NG WVVELLING
C 'I'HE PUBLIC SE'—ER, NEW HOUSE SEWER
SIGNED THIS----DAY --- `-- -�
ONNEC ADDITIONAL — -
0110iER OR '3UIL")T NG CR INCRK_-- __-,�- ..----- ---
U'.VNE.RS AGENT`..��--`—_�_—.___._--..- _FPN, ,,rri.,SEEP,PIT:,,) i
AD L`R R;SS__.r.___.—� AND,@R ORA INFIELD �
' 1 REB 'W
. A K IOLEDGE THAT HAVE VE READ THIS APPLICATION CESSPGC; '; DRYWEIA
AND S,RTE Tf,ST THE: ABOVE IS CORRECT AND AGREE 10 COMPLY
rh iT"r ALL 'COUNTY ORDINANCES AND STATE LAWS REGULATING A.LT`r'R PEYAiR,S=Vl ER.OR � � -
P1,UM TNG 1IND SEWERS. SE,+.;AGE„ISPOSAL SYSTEM -
1 r FR E;Y CERT!FY T 3 AMPRGP£R PROPERLY REGISTERED AND,/OR -.. -. -_ _ _. - .. -- ------ --------'^._---_-
LICENSED AS REQUIRED $Y LOS .ANGELES COUNTY AND STATE' 0- 'SCO PeNEC P (:� AND
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF THE ABOVE "ANn �;nL'u_ SE4FER
DE,SC' IB ) RES;DENTFAL PROPERTY. i ACK 1 L SEPTI 7 N..: -_., I _ ----`---
SIGNATURE EFP. II7 S CEI,SP00LS
OF PERMITTEE.
JOHN A. LAMBIE.COUNTY ENGINEER VALIDATION ROBERT A.WOOD, CHIEF PLEIG.-INSPECTOR
CK. K.G. CASH
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