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APPLICATION FOR PERMIT1
BDIIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
D.partmsnl of E t� Englas" Ari L .¢i4/�
ConatT of Los Angels! Boo REINS
WM J FOX. COUNTY ENGINEER A
C:AYYATT D GRIPFIN EUP T OF CUILDIND LOCALITY gH
FOR APPLICANT TO FILL IN NEAREST'
1 CROSS!T e3 4a
LEGAL O ,
DESCRIPTION LOT NO OWNER ,547-'4 .w
,Ta�jh�J
BLOCK TRACT/G, MAIL E K.��D B/
ADORE88
NO OF BLDGS
SIZE OF LOT NOW ON LOT CITY C TEL NO
USE DI /
BUILDIN63 /DISTRICT NO I GROUP I E MAP
CONTRACTO IA 1 -6 fK PO
AODRES 7 CONNECTION DATA
CITY 1-Iy�T STATION a DEPTH a
REGISTRATION NO 9 y�g 6 L /TJ COUNTY MANHOLE
UPPER REFQENCG
TYPE OF CONNECTION LENGTH FROM
NO DESCRIPTION OF WORK FEE Y Lasa- �lrT M L 70 P L
HOUSE.PUBLIC SEWER CONNECTING TO ® f D SO
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1 00
CONNECT OUEE BLDG OR
WORK C HOUSE
SEWER 1 00 CO IMP NO `l �•
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM 1 00 TRUNK PERMIT NO ROAD PERMIT NO
,DISCONNECT AND ABANDON !EWER STATE ENCROACHMENT
,AND/OR DISPOSAL SYSTEM 1 00 PERMIT NO
SEPTIC TANK SEEPAGE PIT OR
_ PITS AND/OR DRAINFIELD 2 00 INDUSTRIAL
CESSPOOL- DRYWELL -- WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2 00 CHARGES
CONNECTION CHARGE FEE
OWNER'S FERI`UT s I DD
AUTHORIZATION I TOTAL FEE 4 fyREIMBURSEMENT FEE
1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED CON- •APmin
PR
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING OVALS DATE INSPECTOR SSIGNATURE
TO THE PUBLIC SEWER
NEW HOUSE SEWER
SIGNED THIS DAY OF 19'rr !'Q
OWNER OR Yn SSI - - - CONNECT ADDITIONAL
OWNERS AGENT !A_ BUILDING OR WORK
ADDRESS r SEPTIC TANK, SEEP, PIT(SI
AND/OR GRAINFIELD
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION CESSPOOL 0 DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWER OR
01 PLUMBING AND SEW SEWAGE DISPOSAL SYSTEM
I HEREBY CEP THAT 1 AN PROPERLY RHGISTERED NO/OR
LICENSED A! UIRED BY LOS ANGELES COUNTY AND ATE OF DISCONNECT PLUG AND
CALIFORNIA THAT 1 A THE LEGAL OWN La OF ABOVE ABANDON HOUSE SEWER
DESCRIBED RE LF 7T
BACKFILL S) C TANK!
S8[P PITS C
SIGNATURE PERMITTER -� i�
OF PlRYITTEE '
WIWAM J -FOX.CouNTY NalNsan - VALIDATION
, � �D5409� JUL7 4 450 In
By
DEPUTE DEPUTY
_ _ I
,By By
,0 DEPUTY //" DEPUTY