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APPLICATION FOR PERMIT 1
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DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE D6SPOSAL.
Department of County Engineer
County of Los Angeles ADDREING
6 1 7 Jy a s i 4=f1 1 }*
WM. J. FOX, COUNTY ENGINE�R
CASSATT D.GRIFFIN, SUPT OF BUILDING ,LOCALITY
_ FOR APPLICANT TO FILL IN NEAREST�q�
to
LEGAL { _ ,
DESCRIPTILOT NO. OWNER +,,.�,,, k,4
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$LBLOCK .__ON TRACT �'.�,. ' c,4 -� MAIL
"�v,- ' -- — - ADDRESS
r NO. OF BLDGS. .
SIZE OF LOT NOW O . TE . NO.YjCITY � A7_6 -
USE
ie
USE
OF ,5p,
BUILDING 5 i ; i,•'.,t Y. /. /4.f �-' ( ,,�,_.-r.-..>a�.�.+kro" `; DISTRICT N0. GROUP MAP
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CONTRACTOR add + ry
ADDRESS. " ! _1 l,I.,; P e 3 =i y'4 d��4 � 4� __. CONNECTION DATA
CITY 'Jar J�4— a� TEL. NO. AT 6 lu,04 4 - STATION ���- {+a�, ,_fir,- DEPTH
Cl STATE MANHOLE REFERENCE
REGISTRATION NO. ® COUNTY _ UFP�Ct----dqqi >:. /t LOWER
'TYPE "'.6ASyNECTION LENGTH FROM
NO. i DESCRIPTION OFWORKFEE -- Y. CURB `- P.L. M.L.TO F.L.
HOUSE E SEWER CONNECTING TO
PUBLIC SEWER
HOUSE SEWER CONNECTING TO p,
_ PRI�A'1"E DISPOSAL SYSTEM 1.00 II!
CONNECT ADDITIONAL BLDG. OR Co. . /� ,�.. J , .
WORK TO HOUSE SEWER 1.00 IMPNO, OBNp
r�--
i ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM 1.00 {! TRUNK PERMIT NO. ROAD PERMIT NO.
DISCONNECT AND ASANDCN SEWER STATE ENCROACHMENT
j
AND/OR DISPOSAL SYSTEM _1.00 I_
—FERM4T NO.
SEPTIC TANK,SEEPAGE PIT OR
_ FITS AND/OR DP.A NFIF.LD 2.00 i I INDUSTRIAL
CESSpOL- DSY"o4'Ei I,..T �"—".�`._�..—' WASTE APPROVAL
_
SPECIAL CONDITIONS ONLY 2.00_ CHARGES
_.--^---' — ^_ CONNECTION CHARGE FEE
OVR4EE.'S PERMIT $ 11 Go
..,._.__--_�__._m.__,__.�_�. REIMBURSEMENT FEE
AUTHORIZATION
TO
FEE
I HAVE THIS DATE= CONTRACT"FD WITH THE HEREIN NAMED COCl-
TRACTOR TAPPROVALS DATE INSPECTOR'S SIGNATURE
CONNECT THE ABOVE DESCRIBED EXISTING Da;ELLING _�. _
TO THE PUBLICSEWER
NEW HOUSE SEWER
SIGNED THIS DAY OF _ I9__
OWNER OR CONNECT ADDITIONAL
BUILDING OR WORK
OWNERS AGENT.,. ._-----.--'--__—
ADDRESS SEPTIC TANK,SEEP, PIT(S)
AND/OR DRA.INF;FLD_
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL[3DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER, REPAIR, SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM -
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND - -
LICENSED- AS R''DUiRED BY LOS ANGELES COUNTY AND STATE OF
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF THE ABOVE ABANDON HOUSE SEWER
DESCRIBED RESIDENTIAL.PROPERTY. BACKFILL SEPTIC TANKS 0
SEEP, PIT 45D El CESSPOC LS l
SIGNATURE �--
OF PERMITTEE
WILLIAM J. FOX, COUNTY ENGINEER VALIDATION
Cs 2 � 'i7' JA
`°t 1,f a�
BY � BY i _..
DEPUTY - DEPUTY
BY BY
DEPUTY DEPUTY