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6A&464 2D,a-h3 APPLICATION F(:1P PERMIT
I
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING ANIS SAFETY DIVISION a ,D1Na
JOAN A. LAMBIE, County Engineer ORE55_j --_____--
WILLIAM A. JENSEN, Sup'R of Building �
TEAR T "r 'f -
F9R APPLICANT TO PILL IN � o s sr ._ ����
.. OT LGN1 �_,. OWER _
DE5CR9 PION N
_ _
_.—__ _._ _:. t- _._� -s- -•---.. , _-• � __ 111 _ '�____.� .-___ __.. ____._ _._ - .�.
BLOCK TRACT .- ODRESS
NO. oil ELDG.S.
SIZE OF LOT NOW%ON LOT CITY TEL. NO.
USE OF DISTRICT NO GROUP MAP POCF SED BY
BUILD ING5
BK PC,..
f
ONT RA CT"9R_ `.�
ADDRESS-_ � _.—: ...__ - C,OI+INECTIO I3 IATA
STATION DEPTH
CITY " ' "' TEL.
_ - -
f I "P'iA TE MANHOLE REFERENCE / / U3 r'E'R-
REGISTRATION NO..---- �-._� SSS .__,,--.__"-_._ �COU NTY .. .___ .._
_. M1
NO. GC.S.CPIPTION OF WdRK ('EE Tt E OF CONNECTION LENGTH FROM
_.-..__ -_.__._ ____ ..___ _....._.._.� q�.-__
HUUSE 5�4Y ER CONNECT"TNG TO Y, CURB : A.L. M L TOP L
PU c'1 L,.IC SEWER @ $5.00 .-'-�`__ .-.,...f-_., ,..� -_ -
__..-:-i __ �___ --._ : __. ,--._ L �,( JOB NO..
SEPT IC TANK SEEPAGE PIT OR
PITS AND/OR 0
DRAINEtELD Q $10. 0 1 CO.iA°P NO. ,' L_
/
-_ HOu SE SEWER EOrJNECTING _,._ ._._
I--_ TRUNK PERMIT NO- ROAD PERMIT NO
PN VATS PI3POSAL 5YSTEM @ $3.DO i
CONNECT ADDITIONAL BLDG OR { AFFIDAViT-1 WA,yFFSEMlNC RECORD. IrJ TR 'JO. I DA"E
W TRn.TO HOUSE SEWER @ $3.0a
OVERFLOW SFF PAGE F11,DR 4IN FIELD II I
FXTN.,CFSSPOOL,DRYWEL.L MANHOLE @ $5.00
__. ....4-_-._.-. _.-_—r-._.___ p._..___ HWY..OR.ST..WIDENING 1';
T 4L TER,REPAIR OR A94NDON HOUSE l"
SEWER_OR D15POSAL SYSTEM @ 53.00 .--.__. _.-.___ ___._._-_-.--_-._-_..--_.-_-_-._ _.__._.—_ 'j.
STAT'E ENCF?CAC.'.H MEN7
,EMIT NO. _
INDUSTRIAL
WASTE APPROV_ _ _
AL
.,_.--_.._�.. CHARGES
OWNER'S PERMIT ' - a oo - -------------- - - --.� -
AUTHORIZATION TOTAL FEE
CONNECTION CHARGE FEE
'I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- H�ltA BtJ—R SRS.EMEPJ 7gF_EE
TRAC' TO C0N N ECT THE _ABOVE DESCRIBED EXISTING O:WELLING - APPROVALS -__--.
TO C'O PUtiL t: SC W'E R. I DATE INSPECTOR 5 Sl:a 1JATU RE
SIGNED THIS--DAY
OWNER OR. NEW HOUSE SEWER
OWNERS AGENT.- CO!JNECT ADDiTI ON AL -
BUILDING OR WORK
SEPTIC TANK.SEEP,PIT(S) ---�-.�-
I
Ii FRSay A IINOWLE.JGE THAT I HAVE READ THIS APPLICATION AND,OR PRAINFIELD
AND STATE: ``e'r{AT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITHALL COUNT' ORDINANCES AND STATE LAWS REGULATING
PI.UM
I.UM l3iNG AND 5-''V ER.S. CESSPOOL D DRYWELL Q
�. I
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR SEWER OR
L ICENSE'D AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTCM
L-.AL.IFORNI OR TH A7 ,/Cpy+1 ' E LEGAL OWNER OF, AND INTEND TO _- ---- -- '-_-- -- -- - "- _ - -
RESiDf
IN, THE A ,,.v RiBED RESIDENTIAL PROPSRYY. 31SCQNNC fI_l G 4ND r
q" 16ANDON U
' J b-^ ..F-. _ RSIGPA'UHE 3atKFILL SEPTIC TANKS
I7c5, SCO�
LCF PERMITF. S
VALIDATION ROBERT A. WOOD
. SUPERVISINGf?IF_£HA-N1CAL ENGIN
CK. Ml.0. CASH
Iii . ' M 1 9 L: D .L1 `
: AB42LI-6z
fiF.S42D APPLICATION FOR PERMIT
�.
COUNTY OF LOS ANGELES SEWER-SEWAGE 0lSpbSA a
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION
JOHN A. LAA'ISIE, County Engineer —
WILLIAM A. JENSEN, Supt of Building 0
I KCAL I TV -
d
Nl-
ARE T
FOR APPLICANT TO TILL IN ROSS 6TLEGm
DESC R I F i:i0N LOT r o
�AIL
f _
BLOCK ;"RAC ADDRESS
_.. NO F Ei DOS .. -
..,,
SIZE. OF i OT f � �' w. NOW ON LOT CITY F,, t� TEL. NO yt/ �: �,- f:,
USE OF
D;Sl R!CT NO. GRUUP MA,s' PROCESSED BY
BUILDINGS
13K P
CO NTP AC
ADDRESS` CONNECTION DATA
's 5""ATlUN DEPTH
CITS' �.TGL NO. - _—
❑ STA.E --__UPPER
REGISTRATION NO... t._I COUNTY MANHOLE Rt:FE RENCE - L6N�ER
NO C+ESCRIP ION Or WORK FEE _ TYPE OF CONNECTION LENGTH FROM
-.—. W _ ,_. ..- Y 'CURB P.L, M.L.TO P.L.
HOUSE SEW ERCONN ECTINGTO .
PUBLtC.SEW ER C b5.00 C._fV0
.____.-. .___.__ ------rPTIC SEEPAGE PIT OR - J09 NO
PITSAND/OH DRAINI IELD ...Fa' 3 O.i'+O I
HOUSE SEWER CONN CTI NC TO I TRUNK PERMIT NO. ROAD PERMIT NO.
R VATE DISPOSAL SYSTEM @ SS.QQ �y�"
C.ONNEct At D.TIONA_BLOC.OR AFFIDAVIT T WAIVEF, EASE MVIT RECORD. iNSTt4,NO. DATE R,d'
WORK.TO HOUSE SEWER
T CV ERFL,C W S,EPAGE PIT,DRAINF'IELD �
,L,DRYWELL-.M/tNHULF@ $7 i.&
EXT N CLSS G .OQ «
.-_._.. OF?S}".WIDENING
I
ALTER,REPAIR OR ABANDON HOUSE
SEWER OR CI SPUSAL SYSTEM CIS g.3.60
STATE ENCROACHM'_NT 'f"
I Pl:RMIT NO. m_
INDUSTRIAL
.._._
WASTE APPROVAL
___. _._..___. _ _ — ..____..
flIlyR'S PERMIT_ 2 oa
CHARGE FEE
AUTHORIZATION TOTAL FEE
'd HAVE Ar THIS DATE A CONTRACT WITH "THE HEREIN NAMED CON- PLIMB JRSEMF.NT FEE
TRACTOR TO JYNF "I' THE AROV'E DESCRIBED EXISTING' DWELLING _.... T� g_y-pp�y _*..AL_ToTH __
F. PUBL.If SEWER, APPROVALS S � DATEINSPECTORS SIGNATURES
SIGNED TH' _.,_--DAY CF_.__.---.-----,—_„99—_ ---. A
I
OWNER OR NEW HOUSf_'SEWER
OWNERS —------ CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS-
SEPTIC TAN}t,SEEP PIT('S)
I k EBY ACKNOWLEDGE THAT I HAVE READ' THIS APPLICATION. ANDI OR DRAINFIF_LU II
.ANO S','RATF THAT THE ABOVE IS CORRE'C'T AND .AGREE TO COMPLY
W!T"HALI- COUNTY OROINANCES AND STATE LAWS" REGULATING
PiL'Mf3IM1 3 AND 'EWERS.
CESSPOOL ❑ DRYWELL n
I ,_I-` EEIY C R'Iry THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,.SEWER OR '
LICENSED AS REQUIRED BY 114 ANGLES COUNTY AND STATE OF WAGE DISPOSAL SYSTEM I I CALIFORNIA (:F2 THA 7 AM 7HI'eF Ai�' ytdER OF, AND I.NTk- TO L CONNECT PLUG fp{D -
RFSIDC IN rH A.OlE 1. Sl'YY- IS R+'�'I PROPS
SIGNATURE ...'.A' Je .,K-. 4ND N .'3U5F SEWED Y_ _.
O H
OF r- �, jy/'ter y e\�:KF LSEPTTC TANKS I
PE:RM!'T'T- � -f_" - �„.!—&a"14� _. �,.LP.PIT(5J C� CESSPOOi_5• Ell
p ALIDA'TION ROBERT A. WOOD
,a l SUPERVISING MECHANICAL ENGINEER
l` CK. 'M.O. CASH
W`1i
0
'.,.' "1../T x"01 p.YJ .li,°.k'# k ✓ 5.00-
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