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APPLICATION - FOR PERMIT 1
£
DIVISION OF BUMDING AND SAFETY SEWER—SEWAGE DISPOSAL
Department of County Engineer
County of Los Angeles BUILDING
WM.J. FOX, COUNTY ENGINEER ADDRESS
CASSATT D. GRIFFIN.SUP'T of BUILDING LOCALITY
FOR APPLICANT TO FILL IN NEAR£ST '
,_,•,moo.,_,.,._ CROSS ST.
LEGAL
— - — _
DESCRIPTION f LOT NO,_,�,_.a _ OWNER 1
BLOCK TRACT - 1J,AIL ��}-
ADDRESS
NO.OF HLOGS.
SIZE OF LOT NOW ON LOT CITY , TFL. N0,
USE OF
_BUILDINGS DISTRICT NO. GROUP ( MAP
BK PO
...CONTRACTOR ,�,��---=.. _
ADDRESS CONNECTION DATA
CITY TEL. NO. Ley' STATION �, .� s _^DEPTH
,g 0 STATE a "� > IdANHOLE REFERENCE
REGISTRATION NO. �a �"B'' S.�� ❑ COUNTY _-_ +� - PPFR — �*A6e�_3
'�.,_�_ TYRE��ECT! N LENGTH FROM2; , P
NO. DESCRIPTION OF WORK FEE _ JRB P_L. h1�L.TO P.L.
HOUSE SE VER CONNECTING TO_ }
PUBLIC SEWER $
HOUSE SEWER CONNECTING TOJ —
ii PR VATS DISPOSAL SYSTEM_—_ 1 QO
CONNECT ADDITIONAL BLDG. OR J
WORK TOHOJSE SEWER. _ 1 00 I CO. IMP. NO. °� ,� JOB. NO. —
------ --
ALTER OR REPAIR EXISTING j —��- --_..- -- '°� °'1
__SEWER OR DISPOSAL SYSTEM. 1.00 i � 1 TRUNK PERMIT NO. ROAD PERMIT NO.V:4.-
j DISCONNECT AND ABANDON SEWER ! STATE ENCROACHMENT
AND'/OR DI POSAL SYSTEM_ 1.40_I _I .— PERMIT NO.
SEPTIC TANK SEEPAGE PIT OR
AND
AND/OR DPAINFIEL_D 2 00 }} INDUSTRIAL
CESSPOOL DRYW LL � 4ASTE APPROVAL
SPECIAL CONDITIONS ONLY 2.00 ` AR
—�—i,------ CONNECTION CHARGE FEE
MIT --- - - —
OWNER'S PER
_ �_�_ r ; ao
LANDSTATE
HORIZATION TOTAL FEE Iva � I>E14.BURSEMENT FEE y.
VE TH;S CATL .CONTRACTED WITH.THE HEREIN NAMED CON• - .�. AP�j�®'� DATE ;�agP (,TOR55IGN:1fUftE
TOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING _
THE PUBLIC SEWER NEW HOUSE SEWER — ---'--
ED THIS
I - CONNECT ADDITIONAL
ER OR i FUILD3NG CR'vVORK
OWNERS Ai.ET..._._.__.---�......_.__.,.._.� -ADDRESS AND/OR SEPTIC TANK,SEEP,PJT(S)
------. AND/OR DRAINFIELDHEREBYACKNOWLEDGE THAT I HAVE READ THIS APPLIC.ATION CESSPOOL❑ DRYWELL 0
SPATE THAT' THE ABOVE 1S CORRECT AND AGREE TO COh1PLY ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER, REPAIR,SEWER OR
BING AND SEWERS. SEWAGE DISPOSAL SYSTEMHEREBY CERTIFY THAT t Aid PROPERLY REGISTERED AND/ORDISCONNECT PLllG ANII
NSED A$ REQUIRED BY LOS ANGELES COUNTY AND STATE OFFORNIA OR THAT I AM THE LEGAL OWNER OF THc ABOVE ABANDON HOUSE S_.WER
RIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS[]SEEP.PITS) n CESSPOOLS ATURE P RIdITTEE
WILLIAM J. FOXo CouNTY ENGINEER VALIDATION
BY 13Y
DEPUTY DEPUTY
BY BY
-...?�; DEPUTY �" DEPdOTY
76 12-BB T APPLICATION FOR PERMIT
76A'6420
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION FNEAREST
G
JOHN A. LAMBIE. COUNTY ENGINEER y;�#
COLEMAN W. JENKINS, SUPT. OF BUILDING _
FOR APPLICANT TO FML IN T,
LEGAL
DESCRIPTION LOT NO. OWNERI ';-a 1 !}yi" .,;�
MAIL
BLOCK TRACT ADDRESS 5 -
JT >>
NO. OF BLDGS,
SIZE OF OF LOT NOW ON LOT CITY .,fir .; d"'�T L. NO, `°S 9 _ ,� ✓" '
USE OF
BUILDINGS DISTRICT NO. GROUP MAP PROCESSED BY
SK PG
CONTRACTOR
e
ADDRESS D F �,r CONNECTION DATA
CITYL NO A" - - .z"' STATION DEPTH
ATE
LICENSE NO. j,;.c -'� "-:!'r. LIC CLASS �' MANHOLE REFERENCE UPPER
� :_N�>J s?
LOWER
NO, I DESCRIPTION OF WORK FEE `TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TOP.L.
PUBLIC SEWER $5.00 - - -- P.C.NO.
SEPTIC TANK B E AGE PIT OR >
PITS ANO/OR DRAINFIELD @ 610.00 CO.IMP NO. - .)OB.NO. _
PITS
SE SEWER CONNECTING TO 1 J T"
PRIVATE DISPOSAL SYSTEM S9.00 TRUNK PERMIT NO. ROAD PERMIT NO. (�
CONNECT ADDITIONAL BLDG.OR +--~� gFFiDAViT WAIYEt E� ASENENT RECORD.iNSTR,NO.�DATE
WORK 70 HOUSE SEWER a 63.06 1 �
CD
---OVERFLOW SEEPAGE Piz DRAINFIELD
EXTN CESSPOOL,DRY WELL.MAN HOLE@ $5.00 I I I--
ALTER.,f?EPMw-g7F-7i187F-FFpPt-MpI�S� HWY.OR ST.WIDENING LLJ
SEWER OR DISPOSAL SYSTEM $3.40 --'— '_--—"---- .�"S-Z---' - ---
i
-- -- --- —v.- S TATE ENCROACHMEN T
_PERMIT NO, .: / Z
INDUSTRIAL
WASTE APPROVAL .j
t CHARGES
OvWNER'S _PE_RMIT---- ;I , 00 --- ----- --
AUTHORIZATION CONNECTION CHARGE FEE
AUTHORIZATION i1L4 TOTAL FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO-CONNECT THE ABOVE DESCRIBED EXISTING DWELLING --- -- ----
TO THE PUBLIC SEWER. APPROVALS _ DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF ig_ ----------- - --
.OWNER OR NEW HOUSE SEWER
OWNERS.4GENT CONNECT ADDITIONAL
BUILDING OR WORK
SEPTIC TANK,SEEP.PIT(S)
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING '
PLUMBING AND SEWERS. CESSPOOL ClDRYWELL El
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNEC'F`PL UG AND
RESIDE IN, THE ABOVE DESCRIBED RESIDENTIAL P PERTY. gBAN DON HOUSE SEWER
SIGN ATURE �?yBACKFILL SEPTIC TANKS
OF PERMITTEE: SEEP.PIT(S) ❑ CESSPOOLS ❑
VALIDATION JACK R. ALLEN
M.o. egsH
SUPERVISING MECHANICAL ENGINEER