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6A 6420 - CE 08 - 9/73 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEW/ E DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESSI y„
LOCALITY J., ,.
NEAREST x
FOR APPLICANT TO FILL IN
17
LEGAL f t
DESCRIPTION LOT NO. " � �f OWNER - f! I ,,'�
__ L,s MAIL 'p ",.p ♦ .7
BLOCK TRACT j �� ADDRESS L� a
NO. OF BLDG3. J
SIZE OF. LOT NOW ON LOT f�; �j ��c _ CITY ( l' TEL. NO. ,i --"'+ d
USE OF -��- ?—
BUILDINGS �, �,t:>j 1t� '.j _ DISTRICT NO GROU MAP ''PRDCESSED BY
I
BK PS
GONTRACTO ;v I/I " „ o" { �✓
ADDRESS y CONNECTION DATA
..+ = „� _ ,/r STATION / �E �. Cl DEPTH 1"p
STATE { � TEL. NO. / , y
LICENSE NO,.,?-- a.G� GLA35 ir-3 J-C"' F MANHOLE REFERENCE
No, j DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM .
HOUSE SEWER CONNECTING TO .- Y. "'CURB P.L. M.L.TO P.L.
PUBLIC SEWER -
SEPTIC TANK.SEEPAGE PIT OR " P.C.NO.
PITS AND/OR DRAINFIELD ;)¢,Qp CO. IMP.NO. „y f JOB NO,
HOUSE SEWER CONNECTING-i;&------
ONNECTING TO —,.✓-y;: TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM gyp.
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT I wA1YEER�SEKERT RECORD.INSTR.NO.
WORK TO HOUSE SEWER �' d
OVERFLOW SEEPAGE PIT,DRAINFIELD J J',;'•[ C:)EXTN..CESSPOOL,DRYWELL. _ HWY.OR 5T:WIDENING
ALTER,REPAIR OR AS HOUSE
SEWER OR DISPOSALSYSTEM STATE ENCROACHMENT
MAHh OLE --.! PERMIT NO. - .� '• C, T. L i
INDUSTRIAL
WASTE APPROVA -) •`d J. G N
L - °(;-a/"' 's-- ":xY�.l•� r 4.' 'Y Z
CHARGES - —
OWNERyS PERl4trr $ —�
T Ir
AV 1HOiLlZAllOd! TQTAL F�'F, _ ,�,. ",y CONNECTION CHARGE FEE
s L.
ITHAVE AT THIS DATE A CONTRACT WIH THE HEREIN NAMED CON. RE I M BU RSE M ENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER, APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 9
OWNER OR .( -,/ NEW HOUSE SEWER - ,•�f� ' r�� __ _
OWN RS AGENT - >g _
CONNECT ADDITIONAL '
BUILDING OR WORK
1 HEREBY ACKNOWLEDG
♦'THAT 1 HAVE READ THIS APPLICATION SEPTIC TANK,SEEP,PIT(S)
AND/OR DRAINFIELD
AND E��
STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY ----
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/ORALTER,REPAIR.SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFC,RNIA OR THAT 1" M THE LEGAL OWN OF, ANDNNTEND TO DISCONNECT PLUG AND
RESIDE IN, TH +✓ DESCRIBED RESiD. T'<ZL ERTY. ABANDON HOUSE SEWER
SIGNATUREOF PEftMTTT,EE &- �$ '. � - BACKFILL SEPTIC TANKS Cl
SEEP.PIT(S) t}I%SPOOLS Cl
M .E.�
`'sem VALMATIO r CK,S M.0. CASH
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