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CE 80;IREV enol APPLICATION FOR PERMIT '
_ SEWER - SEWAGE DISPOSAL
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN olEml"No I GROUP MAP EK Ps PROC ED BY
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LRT LtA.Q dTYL 110STATE �/ LICEIMBURSEMENT PRESTATE R NO CLAS1NO DESCRIPTION OP WORK FEE � APPROVALS - DATCI VISPECTORSSIGNATURHOUSESEWERCONNECTINGTOPUBLICBEWER SEPTICTANK.SERPAGEPITOR {WHOVf■EWERPRSAND/ORDRAINFIELDONNECTADDITIONALH Un SEWERCONNECTINOTOULLRING OR WORK
PRNATE DISPOSAL SYSTEMEPTTCTANK BnEP PITMICONNECT ADDITIONAL BLDG ORND/OR DRANFIELD
WORK TO HOUSE SEWEROVERFLOW SEEPAGE PIT DRAINFIELDESSPOOL ❑ DRYWELLO
fKTM CESSPOOLDRYWfLLMANHCLf
ALTER REPAIR OR ABANDON HOUSE ALTER REPAIR BCWEROR
SEWER OR DISPOSAL ETSTEM SEWAGE DISPOSAL SYSTEM
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ABANDON HOUSE SEWER
.+ BACKPILLSEPTKi TANKSO -
OWNER'S Permit S SEEP PR1610 CEssPooLs0
AUTHORIZATION TOTAL FEE VALIDATION -
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON -
TRACTOR TO CONNECT THE ABOVE DESCRIBED SKIETING DWELLING ;12735A
TO THE PUBLIC ROWER Y
SIGNED THIS DAYOP 19_ M-S S S E 10
OWNER OR
OWNERS ADEM _ - AT S S , &00--
ADDRESS 00ADDRESS C
AIO STIATE THATK THESove Is CCRRERµo AGREE TO CCOMPPLLY , S S S &005
WITH ALL COUNTY ORDINANGEa AND STATE LANs REGULATING /� q
PWMBINGANDBaWERB . N I M� ! 9
I HEREBY CERTIFY THAT 1 AM PROP I RlGISTERED AND/OR
LICENSED AS REQUIRED BY LOU ANON COUNTY AND STATE OF
CALIPORNIA D ORTH ELROALO OR AN NTENDTORE
SIDE DI THE I 81
SIGNATURE
OF PERM
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11440
APPLICATION FOR PERMIT-
COUNTY OF LOS ANGELES
SEWER-SEWAGE DISPOSAL
DEPAHTN= OF COUNYY ENGII0M
BUILDING AND SAFETY DIVISION DOo TNG D .
roBx A ueoM coma f0eE1R.�r .
CASSATT D GRIFFIN. Soyt of BoBdhbp LOCALITY
NEAREST
FOR AP CANT TO FILL IN CROSS ST
LEOAL
DESCRIPTIOM L OWNER +
BLOC[ TRACT RAIL
ADDRESS
NO OF BLDOS
SITJ:OF LOT NOW ON LDT CI
USE OF
SUIIDINO! D
ISTRICT NO GROUP _ BR YAP M PROCESSED BY '
CONTRACTOR CALIF SEWER CONCO..
ADDRESS 1317 COLEGROVECONNECTION D A
CITY [lNOTION DEPTH�~ HOLE REFERENCE !RC6ISTRATION NO NO pDESCRIP ION OF FEE
gHONLSEPU SEEEWE RCONNECTING TO PETS AND/ORDSRAINFl E1DT OR TTPQ OF CCURB KION LLFROOVERFLOW 9 EPA08 PI'IDMINFIQLD
E[TN CEA L DREMLL YANXOLE HOUSE SEWER CONNECTING TO PCMOPRIVATE DISPOSAL 3TSTfi■ IVP NO JOB NO
CONNECT ADDIT13pNA BLDG OR TRUNE PERMIT NO ROAD PERMIT NO
WORK TO HOUSE BEW 100
ALTER REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
SEWER OR DISPOSAL ST Y 1 00 PERMIT NO
INDUSTRIAL
WASTE AP ROY L
CHARGES
OWNER'S PERMIT S 00 CONNECTION CHARGE FEE
ADTHom%ATION TOTAL FEE REIMBURSEMENT FEE
I HAVE AT THIS DAT[ A CONTRACT WITH THE HEREIN MAYHD CON APPROV DATE INSPECTOR S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED RISTING DWELLING
TO THE PUBLIC 8
SIGNED TH AY OF �I � NEW HOU SEWER - +
OWNER OR 1 CONNECT ADDITIONAL
OWNERIA BUI LID OR WORK
S[PTIC TANK SEEP PIT(S)
ADDRESSAND/OR DRAINFIELD
I XER ACICNOtlL®GE THAT 1 HAVE READ TNI! APPLICATION
AND STAT THAT THYME
I! CORKER AND 61 NA
TO COYPU CFOL9FOOL DRTWELL
WITH AL COUNTY ORDINANCE[ AND STATE LAWS REGULATING ALTER REPAIR SETTER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT I AN PROPERLY REGI D AND/OR DISCONNECT PLUG AND
LICENSED A! REOUIRED ANG COUNTY D STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT ■ tlNER THE 130Y[
DESCRIBED RESIDE L BACIffILL
SIGNATURE CESS 5
OF PERYI
mr /gRImATION _ WOOD
Ill cum SUPERVISING
NINO MYClfCH ANICJLL BNOINSER
AC05987R Kq 11 O A 5.00 t7
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, 1APPLICATION. FOR PERMIT 1
VS&e 06'a DIZON OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL
Department of Conaty Engfnen
County O! Loe Ap9e]ee IN BUILDING
WM J FOX, COUNTY ENGINEER ADDRESS .
CASSATT D GRIRFIN. SUP T or BYILDING LOCALITY
ICANTO FILL
FOR APPLTNEAREST L
CROSS 8T
LEGAL
DESCRIPTION LOT NO OWNER
BLOCK TRACT MAIL
ADDRESS
NO LDG
SIZE OF LOT NOWOF ONBLOT'
CITY TEL NO
USE OF
BUILDINGS DISTRICT NO GROUP MAP
BK PG
CONTRACTOR
ADDRESS CONNECTION DATA
CITY /G L NOPC STATE STATION DEPTH
REGISTRATION NO / / V –9 ❑ CC..OUNTY MANHOLE
REFERENCE LOWER
TYPE OF CONNECTION LENGTH FROM
No DESCRIPTION OF WORK FEE Y CURB P L M L TO P L
'HOUSE SEWER CONNECTING TO
PUBLIC SEWER ® S S SO _
HOUSE SEWER CONNECTING TO
III PRIVATE DISPOSAL SYSTEM 1 00
CONNECT ADDITIONAL BLDG OR CO IMP NO JOB NO
WORK TO HOUSE SEWER 1 00
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM 1 00 TRUNK PERMIT NO ROAD PERMIT NO
DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT
AND/OR DISPOSAL SYSTEM 1 00 PERMIT NO
I SEPTIC TANK SEEPAGE PIT OR
PITS AND/OR DRAINFIELD S 00 INDUSTRIAL
'CESSPOOL- DRYWELL HASTE APPROVAL
'SPECIAL CONDITIONS ONLY Y 00 CHARGES
CONNECTION CHARGE FEE
OWNER'S PERP&T s t 00
AUTHOBIZATION TOTAL PEE REIMBURSEMENT FEE
I HAVE DATETRACTORTTOS CONNECT THEA CTED ABOVE DESCRIBED EXIISTINGWITH THE HEREINA MED DWELL G APPROVALS DATE INSPpkTOR 9 SIGNATURE
TO THE PUBLIC SEWER
? C ST
SIGNED THIS DAY OF 19—
NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING O O K
ADORE9R IC TA EEP 1.
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
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 REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCDISC ON HOUSE'EWER
CALIFORNIA OR THAT I AN THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENT L PROfERTT /-� BACKFILL SE C TANKS[3` A_ - tea/ • SEEP FIT 3 CESSPOOLS
SIGNATURE
OF PfiRYITTEE t
WILLIAM J FOX.COUNTY ENGINEsR VALIDATION
. BY - wju2 �v24 AM 18 4 4_b0 a
DEPUTY DEPUTY-
BY BY
.0 DEPUTY , �j y� '/FSC DEPUTY