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1 APPLICATION- FOR PERMIT
' MBION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL
Deparbnent of County EDglneef 7ILDING
�G
CGGety of LGe Angel" ADDRESS
WM J FOX COUNTY ENGINKER
CABeATT D GRIFFIN.Bw'T of BUILGIMO LDCALTTY j yYl OE leC^
FOR APPLICANT TO FII.I. IN NEE CROSS T N-
LEGAL
d
DESCRIPTION LOT NO OWNER
BLOCK TRACT MAIL
NO OF BLD69
ADOREm ` 7 I
413E OF LOT NOW ON LOT CITY L�@ TEL NO
USE OF
BUILDINGS DIST NO GROUP I BK YAP PQ
CONTRACTORLuld y p /�
I
ADDRESS P♦7- Q"'1 CONNECTION DATA
CITY '
1 TEL NO STATION DEPTH
REGISTRATION NO 1/,O �ATNTY �Al. NANPPER REFERENC6 OWER
TYPE OF CONNECTION `� LGN GTN FROM
NO DESCRIPTION OF WORK FEE Y CURB P Y L TO P L
HOUSE SEWER CONNECTING TO
PUBLIC SEWER ® f ] 60 0
HOUSE SEWER CONNECTING TO RIC, 477
PRIVATE DISPOSAL SYSTEM I DO
CONNECT ADDITIONAL BLDG OR :::z
CO IMP NO JOB NO
WORK TO HOUSE SEWE0. 1 DO
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
SEPTIC TANK SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 2 00 INDUSTRIAL
CESSPOOL-ORYWELL -- WASTE APPROVAL
SPECIAL CONDITION]ONLY 2 00 CHARGES
CONNECTION CHARGE FEE
OvIER'S PERMIT E 1 00
AUTHORIZATION TOTAL PEE REIMBURSEMENT FEE
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE UPPECTOR SSIGNATURE
TO THE PUBLIC SEWER '
4
SIGNED THI OF 19—
NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AG�xr BUILDING OR WORK
SEPTIC TANK SEEP, PIT(f)
ADDRESS AND/OR DRAINFIELD
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 SYMM
1 HEREBY CERTIFY THAT 1 AY PROPERLY REGISTERED AND/OR
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT 1 AY THE LEGAL OW MEy OF TME ABOVE ABANDON HOUSE SEWER
DESCRIBED RESIDENTIAL PROP TY
BACKFILL SEPJJC TANKS
PEEP PRD CESSPOOLS
SIGNATURE
OF PERMITTEE
WILLIAM J.FOX.COUNTY ENGINKm VALIDATION
By _ 'Cos Bit 7 9 OCT 3 4 5.5 0
DEPUTY DEPUTY
By BY f
A DEPUTY