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DEPARTMENT OF COUNTY ENGINEER SEWER-SEWAGE DISPOSAL 1
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES Bml.mxc L
WILLIAM J. FOX, COUNTY ENGINEER I ADDRESS J Z
FOR APPLICANT TO FI L
IoN - LOCALITY
BUILDING ` / NEAREST
ADDRESS ✓ CROSS BT.LOCALITY DISTR�CT�D SERIAL NO. PERMIT NO.
NEARESTID�CROSS ST. Ready far Inspection DAT UEDMAIL t� � USE20NE OCCUPANCY NAP
ADDRESS Sit PC
CRY tTELNO / S /1 177
CONTRACTOR « ' y' /•i "{1�- . 'CO.IMP. NO. /���
ADDRESS JOB NO.
CITY G'l-y.��d ,{' Yl- TELAO. ``,e Fi���itAAT�TEER TRUNK PERMIT NO. -----
REGISTRATION NO.- -- ---
� ROAD PERMI7 NO.
LEGAL
DESCRIPTION LOT O. J r-51
7 J STATE ENCROACHMENT
- PERMIT NO.
BLOCK TRACT �J(� Q INDUSTRIAL
WASTE APPROVAL
SIZE OF LOT LSa X ANO.OF SO NOW ON BLLOIITGS-
CHARGEd
USE OF
BUILDINGS CONNECTION CHARGEE
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO ^ REIMBURSEMENT FEE
PUBLICSEWER a i 3.50 V RECEIPT NO. DATEI BY
HOUSE SEWER CONNECTING TO
PR IVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.OR CEPTIO RECORDED
WORK TO HOUSE SEWER 1.00 06. D TE BY
ALTER OR REPAIR EXISTING
SEWER OR D ISPOSAL SYSTEM 1.00
DISCONNECT AND ABANDON SEWER
ANO/OR DISPOSAL SYSTEM 1.00 CONNECTION DATA
PETS AND/OR DRAINFGELDT OR 2.00 /
CESSPOOL-DRYWELI STATION 3' t�/ O DEPTH
SPECIAL CONDITIONS ONLY 2.00 /-7 / �n MeUAPUS
PE FERENCS/�J���LLL�� CeP----
TYPE OF CONNECTIO LENGTH FROM
OWNERS PERMIT = I Op P.L. M.L.TOP.L.
AUTHORIZATION TOTAL FEE
1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
HAVE
TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER��
SIGNED THIS.---fly-t-.._DAY OF-.aSr'!LSt<�:G t4 19.5.1 NEW HOUSE SEWER
OWNER OR - CONNECT ADDITIONAL
/� r 6� BUILDING OR WORK
OWNERS
AGENT.. -J(YL. .....- -.Lyt/L_f .C-__.-_--_..-.-_-._._
SEPTICADDRESS ^.CAC>j� ---({,r L cy' �.0-- "�I AND/OR
TANK"SEEP.PIT(8)
--{a-�---- - �- ------� ----�- AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS PPLI- CESSPOOL[:] DRYWELL 11
CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER, REPAIR,SEWER OR
REGULATING PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY DISCONNECT PLUG AND
AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN. ABANDON HOUSE SEWER
ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS E
D �/{ (� SEEP.PIT(8)[] CESSPOOLS 2G
SOF PERMNATUITTEE._ !-_.-=- L.__.�.C_a'!-:�L..(." .--!4 �1/� _ T
70A642A 663 7/53 777u .4 -o(.,- J<y.
el
CEROR 3-E9 •_ T
76A542D APPLICATION FOR PER
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL �J
DEPARTMENT OF COUNTY ENGINEER
BUILDING IVISI
AND SAFETY DON BUILDING ��1 /
JOHN A. T,AND County IgVISIr ADDREss
W(SIAM A. JENSEN, Supt of Suilding
LOCAL
NEAREST
FSLOCK
R APPLICANT;FO FILL `NDss Sr. sTro O
q
LOT NO. �( / OWNER
MAIL
TRACT ADDRESS J No NOW ON LOT CITY TEL. NO.
DISTRICT NV.]GROUP MAP PROCESSED BY
SK PG
CONTRACTOR -570 N L
ADDRESS 1 r 'JG STATION
CONNECTION DATA
CITY TEL. NO.`J ( DEPTH
^� T STATE MANHOLE REFERENCE
REGISTRATION NO. / cJSD I7 B COUNTY LOWER
NO.
DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L.
PU BL(C SEWER ® JS.OD
SEPTIC TANK.SEEP..K PIT OR JOB NO. O
O
PITS ANO/OR DRAINFIELD ® {IO,00 CO..IMP. .
HOUSE_SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. U
PRIVATE DISPOSAL SYSTEM 53.00
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT AIY tAa[Y[M RECORD. INSTR.NO. DATE
WORKTO HOUSESEWER ® f3.Go
O
OVERFLOW SEEPAGE PIT.DRAINFIELD V
EXTN_CESS POOL,ORYWELL.MANHOLE 0 $5.00 �- W
ALTER,REPAIR OR ABA NOON HOUSE HWY.Oft ST.WIDENING y
SEWER OR DISPOSAL SYSTEM ® 63.00 N
STATE ENCROACHMENT Z
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
OWNER'S pEAM17 s 21 00 CHARGES
AUTHORIZATION TOTAL FEE O NECTION CHARGE FEE
-1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED Co._ REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS
TO THE PUBLIC SEWER, DATE INSPECTOR
'B SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS SEPTIC TANK.SEEP.PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR GRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
IHEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED ANO/OR ALTER.REPAIR.SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF 5EWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF. AND INTEND TO DISCONNECT PLUG AND
RESIDE IN. THE ABOV ESCRIBEO RE ENTI PROPERTY. ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMITTEE SEEP.PIT(S) ❑ CESSPOOLS ❑
VALIDATION ROBERT A. WOOD
( �R / SUPERVISING MECHANICAL ENGINEER
M.O. CASH
LALO 2 2 5 2 JUN 31 0 D 5.00-