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DEPARTMENT OF COUNTY ENGINEER SEWER-SEWAGE DISPOSAL 1
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER BUILDING
CASSATT D. GRIFFIN, SUPT DF BUILDING ADDRESS
FOR APPLICANT TO FILL IN LOCALITY
BUILDING NEAREST
ADDRESS CROSS ST.
LOCALITY DISTRICT NO. SERIAL NO. PERMIT NO. cc
NEAREST - A 3
CROSS ST. - -
RECEIVED BY Ready for Inspection I DATE ISSUED
OWNER
MAIL
ADDRESS USE ZONE OCCUPANCY BK MAP PG
CITY TEL.NO.
CONTRACTOR CHARGES REIMBURSEMENT FEE
ADDRESS REQUIRED
uNOT REQUIRED
CITU ETEL N0.C' t.'_
'" IDB.N0. CONNECTION CHARGE FEE
STATE
REGISTRATION N0. GC' ,FTY GO.IMP.NO.
LEGAL RECEIPT NO. I DATE BY
DESCRIPTION LOT NO. t=-
BLOCK TRACT ; WAIVER FOR RECORDING
SIZE OF LOT NO.OF BLDGS...
NOW ON LOT RECEIPT NO. ! DATE BY
USE OF
BUILDINGS
_DESCRIPTION, OF WORK FEE TRUNK PERMIT NO.
HOUSE SEWER CONNECTING TO ROAD PERMIT NO.
PUBLICSEWER Q E 3.50
HOUSE SEWER CONNECTING TO STATE ENCROACHMENT
PRIVATE DISPOSAL:SYSTEM 1.00 PERMIT NO.
CONNECT ADDITIONAL BLDG.OR INDUSTRIAL
WORK TO HOUSE SEWER 1.00 WASTE APPROVAL
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM _ 1.00 CONNECTION DATA
DISCONNECT AND ABANDON SEWER —
AND/OR DISPOSAL SYSTEM 1.00 STATION DEPTH
SEPTIC TANK,SEEPAGE PIT OR I
PITS AND/OR DRAINFIELD 2.00 MANHOLE REFERENCE
CESSPOOL—DRYWELL UPPER LOWER
SPECIAL CONDITIONS ONLY 2.00 I I TYPE OF CONNECTION LENGTH FROM
I Y. CURB P.L. M.L.TO P.L.
OWNERS PERMIT 1 00 ---
AUTHORISATION TOTAL FEE �' -
1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER
SIGNED THIS_-----.__._--DAY OF_ ___.- .-.--.-.-- .-- 19._.._..... NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT__......,... ------------------------ BUILDING OR WORK
SEPTIC TANK,SEEP.PIT(S)
ADDRESS_.--.................. - - --------__.......____----- ........ AND!ORDRAINFiELD
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLI- CESSPOOL❑ DRYWELL I
CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER,REPAIR SEWER
REGULATING PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
i HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED DISCONNECT PLUG AND
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOUSE SEWER
AND STATE OF CALIFORNIA OR THAT 1 AM THE LEGAL OWN-
ER OF THE ABOVE,PESCRIBED REEIDENTIAI_ PROPERTY. BACKFILL SEPTIC TANKS(❑
SIGNATURE SEEP.PIT(S)E] CESSPOOLS(
OF PERMITTEE - ---------.-.-:-- -
46A6421) 663 12/52