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APPLICATION FOR PERMIT
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COUNTY OF LOS ANGELESSEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION FAD ss ' c fOH14 A, L.AMBIECounty Eng.inleer 'WILLIAM A, JENSEk. Supt o4 BuildingLOCALITY
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FOR APPLICANT TO FILL IN Ross 5T LE A
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ADDRESSNO. OF BLDS.
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REG: RAl ION iO ,A- 1 �T"`� LJ COUNTY LOWER
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NO.. CIEkRIPT,O'N O� W614K FEtr -- - ---TYFLJ r(,NN r' JN LENGTH FROM -�
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HOU t-SENER ,ON!E TING 70. Y. Ft'��.,5 -: P P.L. �
,_PUBLIC SEWER @ $ .00 M.L.__ --
-ETTI(. TANK 5 EPACE P-IT OR-
P.C.NO-
PIT'S
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fT AND DRAINFI LD @ S10G00 I CQ. IMP TO. JOB NO,
-__ :O.NNCl _;_Na-O__.-_ TRUNK PERMIT ROAD FER
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PR VATS D SPCSAL SYSTEM S3.00 AFFIDAVIT WPavER L_EASEE`Y
I RE'l OFcid. INS7R NO IT DATE _..-.
WORK TO HOUSESEWER
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OVERFLOW SE_PAGE PIT.GRAINFIELD
X N,CE FQ JL,DRrWELL,M4NIiOL:E C $5,00
ALTER,REPAIR ORABA—NDONO '—_ HW v.
_OR ST-_WIDENING
SEWER OR DISPOSAL SYSTEM @ $3:G0
STATE ENCP.AC EN'?'
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I WASTE APPROVAL
OWNER'S ERoU --- - - - -- ------- --.. —__..
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CONNECTION CHARGE FEE
AUTHORIZATION TOTALIIT FEE
HAVE AT' THIS DATE A CONTRACT WITH THE HEREIN14AMED CON- REIMBURSEMENT FEE
TRACTOR TO CO INECT THE ABOVE DESCRIBED EXIST[KG DWELLING -- - — ---- -� — ---- -- -_ ---
TO THE PUBLIC SEWER. -- APPROVALS____ JA £ �1NS"FETOR S SIGNATI�RE
SIGNED THIS
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NEW HOUSE SEWER I I
OVV NE RS AGENT— Y,X ___-.-_ ___--__
CONNECT ADDiTION.44. .
ADDRESSBUILDING OR WORK
- SEPTIC TANK SEEP Pil(s) �..
I H--EBA KN r-ED E THAT I HAVE READ THISAPDL AT!ON
AND STATE THAT .HE ABOVE IS CORRECT AP40 AGREE' AND/OR DRAINF LD
WITH4`LL
CO'UN Y ORDINANCES AND STATE LAWS REGULATH41
PLUY..P,NG ANS. jFWEHS CESSPOOL I_J DRYWELL
---- ---__-. — ---1-- --- ----.__
I HEREBY GER'TIFY THAT 1 AM PROPERLY REGISTERED AND/GR ALTER{ EFIiR.SEN'�R OR �
LICENSED AS REQUIRED SY AM,
.ANGLES COUNTY AND STATE OF SEWAGE,a IS P05AL SYSTEM
CALIFORNIA OR THAT I AM THF LEGAL OWNER OF, AND INTEND TO
RE
SIDE IN, THE AE50
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fRABANDON H
OUSE SEWER
SIGNATURE e
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BACKFILL LPrIC TANKS
OF PERM.ITT'E0
SEt P.F,T{.$) ❑ CESSPOOLS [.Ii
VALIDATION ROBERT A. WOOD
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SU'PERVISf NG NIECHANICAL.. ENGINEER
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76A64 t2n APPLICATION FOR PERMIT
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COUNTY OF LOB ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION FADDRr
DING y
JOHN A. LAX1 BIE, County Engineer b'11ILL1AM A, IENSEN, Supt of Building
LITI� .+cEST
FOR APPLICANT TO FILL IN
CROSS'sr
c r LOT NO OWNER
D_:SCF PION -
MAILj,�l�q � �
TRACT /l ADORES,a"Cq-"' - Z-,-'f
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_ 1NO. OF 'BL.DGS. -=G eL:
SIZE OF' d_OT 'T4OVJ ON L.OT ,;a CITY -
'Y'- 'sr,._.w,b EL. ND.
USE OF
BU;LDINGS q-?`" T y--yS �' DISTRICT NO, GROUP MAP PROCESSED BY
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CONTRACTOR ��'4r'''C.'.;y� �°I';.�','C ,y J ',,. !' 7 a'�"v, - P !0 4 4 1 ✓�
4DDRE e' ,�` ' r ,�' r r t.;"�' -^`', CO NIECTION DATA
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,.� d3, �,•-" -... ST AOk ./ t ._ DE;PTH
CT`i ✓.: r� 1
TEL_ N.O. Cd # �`'
a,y" µs -' Lj��^-LATE MANHOLE REFERENCE
P G15 DATION NO .� i. .�.:�.. p" _ COUNTY ,:r .OWER -
NO I DES-cRiinf 66N OF WORK FEE TYPE OF CONNF, TION ' L LENGTH FROM
7u,E SEWER CONNECTING To
T-
PJSI IC.SEWER w5.00 f -" � _-- - --- "'
-- - - -- - `. P.0 NO
SEPTIC TANK,SEEPAGE PIT OR
PTS AICD OR DRAINFILLD - ( $IO.OU CO.:IMP.Np. ,� __-- JOS NO.
R
1901 SE SE MEk EON NELT INC;T'O I _.._._.. .h
RIVAL'E.DISPOSALS STEM � $.3.00
TRUNK PERMIT'NO. ROAD PER IT^.�✓�
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-- _
'JN NEC;7 ADDITIONAL Bl_DC OR —__..__ ..�^t ._
AFFtDAV.T i wnlvett EASEMEN'f�--R_�. RD. INSTR NO I DATE`
t W ORK TO HOUSE SEWER
OVr R>'LOW
----SEEPAGEYI T.f]RAINF'IELU i
EXTPtc'.L -O t_.DRYW LLL,M 73i Ol.E 'iL S.CG HWY.OR 5T',WfC>ENiNG z
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SEWER OR D15POSAL SYSTEM °@ $'3..00
STATE ENCROACHMENT -
____-_.. PERMIT NO. _
J INDIUSTRIk
WASTE APPROVAL •I i ' l+s' _!
CHARGES
OWNER'S PERMIT
NP:CTION CHARGE FEE.
AUTHORIZATION TOTAL FEE CON
_ -: i' -N -- -- - -- -- -- - -- ------ --- _
I HAVE AT THIS DATE A CONTRACT WITH THE HERRN NAMED CON,: REIMBURSEMENT FEE
RA,T0R TO CONNU'-I' THEN ABOVE DESCRIBED EXISTING DWELLING _.�__ - __ -_- __--_. -.-_.— -__. _..____
. TtiE PUBLIC. SEWER. APPROVALS ! DATE �iNSPEC"iOR 5 NATURE
____
S[GN€CI THIS. ----CF#Y C�'._._.-- -- -'--�-43-- - -- - --- ---t- --_..� .--
OWNER OR NEW HOUSE SEWErR } -.-
OWFiI RY.A•vEN __—_____.__ —__ __._._— __.__ .—_— CONNECT ADDI'f3ON.AL
BUILDING OR WORK I '
' .._ ,
.. SEP-
_t_t TANK
._-_S_E.EP_P
IT(5.__)
EREBY ACKNOWLEDGE THAT HAVE READ THIS APPLICATION AND/0R D2A1VF1ED
ANDMC THAT HF ABOVE15 CORRECT AND ArREL TO COMPLY
AL COUN.YORDINANCEAND STA-,P LAWS REGULATING LRLIJMH:NGAND SEW R5- CESSPOOL .
DPYW EL,L i
I HEREBY CERTIFY THAT i .AM PROPS LY REGISTEREO AND(OR ALTER,REPAIR,SEWER OR
3CENS.e AS .?GLARED 13Y LOS ANGLE'S COUNTY AND STATE OF SEWAGEDISPOSALS STEM
CA LI F'ORNIA OR THAT I" ThiE LEGAL OWNER OF AND INTEND TO
DISCONNECT FLU- AND
R SID ! THEABG D SC.R.ILF0 RES T+<"P OPERTY
ABANDCN HOUSE 5EWER I
OF PERM BACKFILL SEPTIC 'TANKS 0
S 11_.,r,F,T(S) F CESSPOOLS
VALIDATION ROBERT A. WOOD
CK, Ni.0. CASH
SUPERVISING MECHANICAL E,ENGINEERf'