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pID �J APPLICATION, k RMIT
e 0&XdeD1rE
IiMON OF BUMDING AND SAFETY SEWER—SEWAGE DISPOSAL
DDporI - of County Enginwr
County O1 Lon AngO(p BUILDING
` WM J FOX. COUNTY ENGINEER ADDRESS
CABBATT D GRIPPIN,BU!T OF BOILDIMO LOCALRY
FOR Apf.LICPNT TO FILL IR
[ADDRESS
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ING! DICT N I GROUP YAP
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ACTOR
CONNECTION DATA
STATIOp DEPTH❑ STATE FERENCE
TRATION MO ❑ COUNTY UPPER [d.
TYPE OF CONNECTION LENGTH FROM /D
NO DESCRIPTION OF WORK FEE IT CURB P L M L TD P L
HOUSE SEWER CONNECTING TO w
PUBLIC SEWER ® S 350 1_ O
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM too
CONNECT ADDITIONAL BLDG OR CO EYP NO NO
WORK TO HOUSE SEWER 1 00
ALTER OR REPAIR EIIISTING y
SEWER OR DISPOSAL SYSTEM 1 00 TRUNK PERMIT NO ROAD PERMIT NO
DISCONNECT AND ABANDON SEWER STA CROACHYENT
ANO/OR DISPOSAL SYSTEM 1 00 PERMIT
SEPTIC TANK SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 2 00 INDUSTRIAL
CESSPOOL-ORYW fiLL -- WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2 DO
-- CONNECTION CHARGE FEE
OWNER'S FEMT S 1 00
AUTHORIZATIO
NTOTAL FEE REINBURSFMEWAE
TRACTORHAVE THIS DATE TO CONNECT THEACTED ABOVEWITH THE DESCR DESCRIBEDEREIN EKISTINGA M ED CON.
DWELLING APPROVALS DATE INSPECTOR S SIGNATURE
TO THE PUBLIC SEWER
NEW HOUSE SEWER
SIGNED THI D OF 19
OWNEROR CONNECT ADDITIONAL
OWNERS A EX BUILDING OR WORK
ADDRES "ND/ T
ORDRAIR FIELDPITIll
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APP TION CESSPOOL❑ DRYWELL❑
AMD
STATE THAT THE ABOVE IS CORRECT
AND AGREE TO OMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTSR. REPAIRS gEWER OR -
PLUMBING AND SEWERS SEWAGE DISP09AL SYSTfiY
1 HEREBY CERTIFY THAT 1 AN PROPERLY REGISTERED AND/OR G AND
PLUG LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON DISCONNECT PLU(EWER
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVEHOUSE
DESCRIBED RESIDENTIAL PROPERTY BACKFILL SEP C TANRS❑
BE LP PIT 8 CESSPOOLS
SIGNATURE
OF PERMITTEE
WILLIAM J FOX.COUNTY ENOENS:ER VALIDATION -
` Br - _ _ &5 6Y0 51S JnL13 4 4450
DEI'UT' DEPUTY
BY BY
m DEPUTY DEPUTY
cEDGeAPPLICATION FOR PZRMIT
TeAaTZD
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL u
DEPARTMENT OF COUNTY ENGIIiEER
BUILDING AND SAFETY DIVISION BUILDING �- O
WM]OFQ( A LAVISM Corny EB=puoft ADDRESS
A IENM, SGP t of Bwldmy r—G
LDuurr
NEAREST
FOR APPLICANT TO FILL IN CACDS BT
DAL Q
D[BCflIFT10N LOF XO ` IOWNE
MAI ioa,
[LOCH TRACT AD 86
NO OP SLDOS 1
SIZE OF LOT NOW ON LOT CT' TEL NO
UBE OP
[UILDINGS DISTRICT NO Oq0 MAP PROCESSED SY
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CONTRACTOR /Q(J}/
ADDRESS 2 CO CT[O DATA
CITYTEL B STATION ./ DEPTH
q STAT[ J UPP
74
REGISTRATION NO L OUNTY MANHOLE REFERENCE
rvo DESCRIPTION OF WORK PEE G TYPE OF CO NN[CTION LENGTH IR
HOUSE SEWER CONNECTING TO Y CURS P L ML TOP L
PU ELIC SEWER 0 Sam PC NO
SEPTICTANK SEEPAOEPIT OR CO IMP NO
PITS AND/OR DRA"FIELD a E1000
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO
PRIVATE DISPOSAL SYSTEM O Sam
CONNECT ADDITIONAL BLDG OR AIIIpAVIT IluvaL [L[[Y[RT RECORD IXSTR NO DATE
WORK TO HOUSE SEWER a 5300
OVERFLOW SEEPAGE PIT GRAINFIELD
EXTN CESSPOOL,ORYWELL MANHOLE O SOW HWY OR ST WIDENING
ALTER REPAIR OR ABANDON HOUR[
SEWER OR DISPOSAL SYSTEM a $3 OO STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
�� WASTE APPROVAL
O n��F1�y[[SCHARGES
FEBbIIT _ s z o0
CONNECTION CHARD[FEE
AUTHORIZATION TOTAL FEE
1RHAVE AT THIS DATE A CONTRACT WITH THE HEREIN AMLD CON REIMBURSEMENT FEE
�Q
TACTOR TO CONNECT THE ABOVE DESCRIBED EXISTINO DWELLING
EWAPPROVALS TO THE PUBLIC BER T8 ATU [
INSPECTO BBIGN
SIGNED THIS DAY OF 1S_
OWNER OR /j NEW HOUSE SEWER Qilt
i rsIZ5
OWNERS AGENT 4I L P
CONNECT ADDITIONAL
_ - BUILDING OR WORK
ADDRESS
SKIPTIC1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR
BEEP PIT(S)
AND STATE THAT THE ABOVE ID CORRECT AND AGREE TO COMPLY AND/OR pRA1NFIELD _
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ ORYWELL ❑
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AMD/OR ALTER REPAIR SEWER OR
LICENSED AS REQUIRED BY LOB ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF ND INTEND TO DISCONNECT PLUG AND
RESIDE IN THE ABOVE GRIBEO R8 NTIAL PR PERTY
ABANDON HOUSE SEWER
SIGNATURE ERM DACKFILLS[PTIC TANKS ❑
OF PERM=EE DEEP PIT(s) ❑ CESSPOOLS
VAIMfl'1'IOIIY'� RING MEC A WOOD
CK M o cA[H/) SUPERVISING MECHANICAL ENGINEER
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