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IDEPARTMLNT OF COUNTY ENGINEER SEWER--SEWAGE DISPOSAL]
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELS8
WILLIAM J. FOX, COUNTY ENOINEER BUILDESS
ING
FOR APPLIT O FILL IN LOCALITY
BUILDING T NEAREST
ADDRESS CR058 ST.
LOCALITY 1 G /'. DISTRICT NO. SERIAL NO. PERMIT NO.
NEAREST 1
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CROSS BT
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REVIVED BY fleetly for Inspection DATE ISSUED y
OWNER I / :/
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CITY TEL.NO.
CONTRACTOR 'njif(1Tnia C M + CO.IMP.NO.
ADDRESS 1317 ("n' P9r0VEL Alla- JOB.NO.
CITY Mnn.tebPlln TEL.NO.�-0w �1��A o TRUNK PERMIT NO.
REGISTRATION NO. 104445 cT1 tSOlIN
3+: :SWT ROAD PERMIT N0.
LEGAL /7— //Q��/'��L
DESCRIPTION LOT NO. J'1.�- ! Z STATE ENCROACHMENT
(?
PERMIT N0.
BLOCK TRACT76 gQ — ,J� j INDUSTRIAL
WASTE APPROVAL
812E OF LOT ''// NO.OF BL DGS.
Tb NOW ON LOT I CHARGES
USE OF
BUILDINGS CONNECTI6A14ARGE FEE
NO. DESCRIPTION OF WORK FEE '
HOUSE SEWER CONNECTING TO REIMBURSEMENT FEE``
PUSLICSEWER e S 3.50 RECEIPT NO. I DATE IBy
HOUSE SEWER CONNECTING TO -
PRIVATEDISPOSALSYSTEM 1.00
CONNECT AO DITI BLDG.OR EXCEPTION RECORDED
SEWS ,
WORK TO HOUSE SEWER 1.00 '
ALTER OR REPAIR EXISTING NO' I DATE
SEWER ORDISPOSAL SYSTEM 1.00
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1.00 CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR
_ PITS ANO/OR DRAINFIELD 2.00 /L
CESSPOOL—DRYWELL STATION 7 �- 5- DEPTH
SPECIAL CONDITIONS ONLY C / MANHOLE REFERENCE
y d � UPPER ramitilt
TYPE OF CO NECTI ` LENGTH FROM
OWNERS PERMIT f I 00 P.`.' M.L.TO P.L. U
AUTHORIZATION TOTAL FEE C t)
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO THE P_ UJiLIC SEWERSIGNE
OWNER THIS__..-_.DA ....L..d 19.?.� NEW HCT ADDITIONAL
OWNER OR /�/r CONN ECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
SEPTIC TANK,SEEP.PIT(8)
ADDRESS......... _. .. .. .... ...A-----.... AND/OR GRAINFIELD
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLI- CESSPOOL 0 DRYWELL E]
CA
TIONAND 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
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED DISCONNECT PLUG AND
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY
AND STATE OF CALIFORNIA OR THAT I AM THE LEDAL OWN- ABANDON HOUSESEWER
F THE ER 0DESCRIBED RESIDENTIAL PROPERT BACKFILL SEPTIC TANKS
SIGNATOF URE
DEB L� - SEEP.PIT(S)E] CESSPOOLS E
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APPLICATION FOR PERMIT
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NEAREST
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LEGAL
DESCRIPTION LOT NO OWN
BLOCK TRACT MAIL
ADDRESS 6 4-4 VIX
NO OF BLDGS • C O
SIZE OP IDT NOW ON LOT C d—
USE OF
BUILDINGS DISTRICTDISTMICT N04"OswRK YAP PROCESSED BY
CONTRACT ;ATS
ADDRESS i C CO CnON DATA
CITY ed TELNO0 / , ODEPTH
NXOLE SEFERENCS
REGISTRATI N YO COUNTY J
N° I
DESC���� ERIPTION OF W R [
PUBLICSSEWEKRKCONN[CTING TO SS 00
EEPTIC T 6NNR SEEPAGE PIT OR TYPE OF CONNECTION LENGTH FROM
PIT!AND OR ORAINFIEID T CURB P Y L TO P
OVERFLOW SEfiPAGE PIT DRAINFIELD
NO SE WEPT CONNECTING TO C NO
HoPR
NN1E A N1�I, CO IVP NO JOB NO
R TO XO 1F176WER�G OR31.00 TRUNK PERMIT NO ROAD PERMIT NO
A T PAIR OR BAN N HOUSE STATE ENCROACHMENT
IN bigg ;w if
31 01) PERMIT NO
INDUSTRIAL
WITS APPROVAL
CHARGES
OWNER'S PIDDQ2 CONNECTIQN CHARGE FEE
AUMOBMTION TOTAL FF.E REIMBURSEMENT FE[
TRACTOR TO CONHAVE AT THIS NECT THE ABOVETE A 'DESCNRIBED EXIISSTHE IING DWELLING NAMED APPROV DATE INSPECTOR°SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS DAY OF IS_ NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADD SEPTIC TANK SEEP PIT(S)
AND OR DBAIMFIELD
I XKRKBT ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STAT[ THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL DRTWEL
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER RHPA10. SEWER OR
PLUMBING AND SEWHBS SEWAGE DISPOSAL$Y [
I HERBST CERTIFY THAT 1 AN PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AN TH L OWNER THS ABOVE
DESCRIBED RISIDERTIA BACKFILL SS CTANK9
SIGNATURE _ SEEP NTS cmr22Ls
OF PENN]
AIION ROBERT A WOOD
(!.,4' L 4 CA.Y YUPIERV1SING A ECNANICAL.ENGIN®[
U60 7 s 10 JA25 1 i D 25.00- 0
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7CEBOB GA64Z0 APPLICATION FOR PER IT
Tan aACOUNTY OF LOS ANGELES
SEWER-SEWAGE DISPO AL
DEPARTMENT OF COUNTY ENI
BUILDING AND SAFETY DIVISIONBUILDING
JOHN A, LAMSIE. County Ev ' ADDRESS
WILLIAM A JENSEN, SuD't of B. LOCALITY
NEAREST
FOR APPLICANT TO FCR09S ST.
LEGAL OWNER
DESCRIPTION LOT N0.
BLOCK T760 PAIL E-
NO
NO.OF SLOG -
SIZE OF LOT NOW ON LOTCITY EL. NO
USE BUILDINGS
Dl!TNCT NO. GROU MAP PROCESS Y
R Pq
CONTRACTOR• LP
ADDRESS,o CONNECTION DATA
CRY TEL NO. t- AONDEPTH
STATE REGISTRATION NO. OUNT MANHOLE REFERENCE UPPER
NO. DESCRIPTION OF FEHOUSE SEWER CONNECTING TO
PUBLIC SEWER @' TYPE OF CONNECTION LENGTH FR MSEPTIC TANK,SEEPAGE PIT ORY. C B P.L M.L TO P.L. JPITS AND OR DRAINFIELD OVERFLOW SEEPAGE PIT.DRAINFIELD EXTN.,CESSPOOL.DRTWELL aHOUSE SEWER CONNECTING TO P.C. o. OUPRIVATE DISPOSAL SYSTEM @ . CO.IMP. X0. JOB N0.
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT NO.
WORK TO HOUSE SEWER SI.00 O
ALTEfl REPAIR OR ABANDON HOUSE @ $
I.00 STATE ENCROACHMENT G
L SYSTEM
PERMIT NO.
INDUSTRIAL W
WASTE APPROVAL
N
CHARGE! Z
OWNERS PERMIT f Z 00 CONNECTION CHARGE FEE
AUTHORIZATION rTOTAL FEE REIMBURSEMENT FEE
I NAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'!SI RE
TO THE PUBLIC SEWER.
SIGNED THIS DAY OF 19— MEW HOUSE SEWER '
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
SEPTIC TANK,SEEP.PIT(S)
ADORES. AMD/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL Ej ORYWELL
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT 1 AM PROP RED ANO/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANG S COUNTY A TE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AN THE LE L OWNER 0 HE E
DESCRIBED RESIDENTIAL ROP T� BACKFILL SEPTIC TANKS
SIGNATURE EP.PIT 9 CESSPOOL9
OF PERMITTE VQ /
A].IDATION ROBERT A. WOOD
cc ■ o SUPERVISING MECHANICAL ]ENGINEER
Or
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