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;GADS 10 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER C� gry
BUILDING AND SAFETY DIVISION gBLDING
BUI
JOHN A. LAMBIE, COUNTY ENGINEER poREsS
COLEMAN W. JENKINS, SUPT, OF BUILDING
LOCALITY a� �i•-�-- �T
NEAREST /
FOR APPLICANT TO FILL IN CROSS ST.OeWljZ'W�
LEGAL _ --- �• ./"�-�_ _
DESCRIPTION LOT'NO. -' 3 OWNER /` +, ;-/}�.�/ '✓/7 ,4,(3y�.pl ,
BLOCK TRACT ,f 6 2 L-d MAIL ADDRESS�_.
�' �'� S/
PO. OF
SIZE OF LOT NOW ON LOTS CITY ! f,,. L •�'y
USE OF ...-. R i _ ✓Lv� s�aG �I'�r TEL. NO. y"vly�Q�'."
BUILDINGS - ,+ _% DISTRICT NO. GROUP MAP PROCESSED BY
BK
CONTRACTOR v-- �'- K e_- E A_,
*
ADDRESS CONNECTION DATA
CITY TEL. NO. STATION P DEPT14 ,
STATE LIC MANHOLE REFERENCE r `
LICENSE`.NO, -CLASS t t A' LOWER
NO. DESCRIPTION OF WORK^ FEE
TYPE OF CONNECTION LEN TH FR
HOUSE SEWER CONNECTING TO ..may Y RB ' P,L. M.I. TO P.L.
RUBLIC SEWER 55.00 (�' "—..—
SEPTIC TANK SEEPAGE PIT OR -- _ — P.C.NO.
PITS AND/OR DRAfNFIfLD @ .;10:00 GO. MP.'N O.I .JOB NO.
NOUS[SzWER CON NECTlNG TO /ry +�,r-y t r
!PRIVATE DISPOSAL SYSTEM 53.00 I TRUNK PERMIT NO, ROAD PERMIT NO.
—ICON NECT ADDITIONAL BLDG OR —^�— AFFIDAVIT WAIVER EAB£M[NT REC bRD.INSTR.NO. l ,/1DALTE
WORK TO HOUSE SEWER $3-00
OV FRFLOW SEEPAGE T.DRAINFIEI.Di�_
EX TN..CESSPOOL.-RYWELL.MANHOLE Q $5.00
- -J----^--- ---- H W Y.OR ST.WIDENING
ALTER.REPAIR OR ABA ND0IV HOUSE -----�--�^
SEWER OR DISPOSAL SYSTEM $3.00 I - -_--.. ..-_____.___.__�___._._._.______- -__ d
____-..__ ENCROACHMENT
PERMIT NO. fr)
'F-'-- INDUSTRIAL
1 ---.-.__. Y+-ASTE APPROVAL . --_.--- -_.- -
- -�� CHARGES
OWNER'S PERMIT — -- $! 2i oo ---------- - — ---
AUTHORIZATION TOTAL FEE t t) CONNECTION CHARGE FEE -
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAME- CION- REIMBURSEMENT FEE
TRACTOR T0.CONNECT THE ABOVE DESCRIBED €X1:57 ING DWELLING - ------
7.0 THE PUBLIC SEWER. APPROVALS DATE INSPECTOR'S 141GNATURE
SIGNED THIS DAY OF 18_ _-_---__---- - .'
OWNER OR NEW HOUSE SEWER
OWNERS AGENT` -
- f.ON NECT ADDITIONAL -
BUILDING OR WORK
IC
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION SEP
/O TANK.SEEP,PIT(S)
ANDOR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ❑
PLU Mi GING AND SEWERS. CESSPOOL ❑ DRYWELL
IHEREBY CERTIFY THAT I AM PROPERLY REGI TERED AND/OR ALTER,REPAIR.SEWER OR
LICENSED AS REQUIRED BY LOS ANGI_"' COUNT AND STATE OF SEWAGE DISPOSAL SYSTEM 0, /
CALIFORNIA OR THAT THE LEGAL W ER O AND INTEND TO --- "----' l —
RESIDE IN, THE ASOJo-E SC IBED ID N7 DPfR )
'SCONNEH PLUG AND
+' ABANDON HOUSE SEWER
_�_ __ _ w JIT
SiO NATURE BACKFILL SEPTIC AN
OF PERMITTEE SEEP,PIT(5) �`ysCESSP OLS '
VALIDATION JACK R. ALLEN
CK. M.b.
SUPERVISING MECHANICAL ENGINEER
ASH
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