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75A6420 APPLICATION FOR PERMIT`
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING FIND SAFETY DIVISION BUILDING .�
JOHN A. LAMBIE, County Engines —
WILLIAM A. JENSEN, Supt o4 Building 1
LOCALITYa�5.""u' ..U"."' - ♦ a
FOR APPLICANT TO FILLIN CROSS ST. 9
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LEGAL �
DESCRIPTION L07 NO, OWOWNERJ'y"
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A
M
1- L.,
BLOCK TRACT '� +� g.- ADDRESS
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NO. OF SLOGS.
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SIZE OF LOT NOW ON LOT CITY - ril_. )•t 0.
Use
BUILDING.; DISTRICT N0. CiROU^ .. ap v;R CES:SED BY
CONTRACTOR
:ADDRESS ` �'� �' Cdr:"� �"- __._. CONNECTION DATA - - -
'� fld.® r yF ba.;.� s f-- y. __.-._. STATION
r iT'Y;", '" l EL N'.L., " T ,
rR STATE
REGISTRATION NO I Tx C P MANHOLE REFERENCE -
_. ..__. --_ __ +.. _,� _-__.. COUNTY
-- .-CTI_
Nb � DESGRIPFION OF WORK FEE - _ - TYPE oscoNVEcr!oN tENr tt FRO � -----
HOUSE SEWER CONNECTING TO Y. CURB P.L M.L T"P.L.
PU P)I C SEW FT2 @
_ _ _ .__ J•'_ - P.C.NO - -J —�--_- 3P
i _._ V
SEPTIC TANK y
SEEPAGE PI OR
PITS AND'OR URAiNFIrLD $10:00 _-CO. IMP. NO.
i
HOUSE SEWER COWIN ING TO")DISPOSAL !'I _tiNK PERMIT NO ROAD PERMIT NO.
. PRIVATE DISPOSAL SYSTEM �� 33-.00
9���lIII
O ANFC-,AUL],,-60NAL BLDG OR
-- - --- .-�-- � - - Ah IDAYIT I wptYFR ¢nseBr Ew T� RECORD iNSTR NO-�� DAT
WORK TO HOUSE SEWER @ $'}00
_D D
iOVFR.FLOW SEEPAGE PTT ORAfNP1ELD
EXTN.CEbSPOOL.DRYW ELL,MANliOLE� $5 00
_L Ac.IER.REPAIR OR ABA:N DON HC[;SE - - - F14V'd. CiR Sl WiC1=.N I'FG
SEWER OR DISPOSAL SYSTEM $i},00.
STATE ENCROACHMENT
I. PERMIT NO..
..
WASTE APPROVAL -
E:wcHARGEs
2! 00
OVMS PERMIT
-- --- - - •�i r, CONNECTION CHARGE FEE -
AUTHORIZATION TOTAL �
I HAVE AT THIS DATE A CONTRACT WITH THE' HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR ID CON NEGT THE. A80VE DESG.RI[3•`_U E%IST!_NG UWFLL?N(; - - - - - -
APPROVALS
1'O 1'H£ PUBLIC 5EW E"¢. DATE: INSP EC70R S SIGNATURE
SIGNED THIS --- -DAY OF,----------'�-- – --- -- - --- -�----- --- ------
0,
`--0,W-F.R OR
�{1 NEW HOUSE:'-SEWER
OWNERSAGENT�
I {I-
"'---' `-- ---'-- -- CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK -
--_-_-
---- - -- - -- - SEPTIC:TANK,SEEP,FIT[S)
IHEREBY ACKNOWLEDGE- THAT , HAVE READ THIS APPLICATION - �
ANO:OP D<AINFIftD
ANC A'E THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY
WIT, ALL COUNTY ORDINANC€:S AND STATE LAWS REGULATING '
PLt:MSING AND _EWERS. CESSPOOL. 1-1 ORYWELL [�
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR ALTER.REPAIR..SEWER OR
LICENSED AS REQU IREO By
LOS ANGLESCOUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
C'4Li r`ORNIA OR THAT I 'AM 7HG LLt AL OWNER OF, AND INTEND 70 DISCONNECT P{_:IG AND - ----_ -__ _--
RESIDE IN. THE. ABPVO 'DESCRIBED RESitEN.TIAL PROPERTY. ABANDON HOUSE SEWER -�
SIGNATURE ',q ¢ �y,.y{/C_,��} BACKFILL SEPTIC.TANKS t� `u - -
bf' PER MTT7E rd-__ y.�._ _ - s -- .aEE P,PIT[S) CE55POOLS
VALIDATION ROBERT A. WOOD
1.
CK. M.G. C;1.SH SUPERVISING MECHANICAL ENGINEER
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