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6A6420 SAPPLICATION F R PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION r3kjiLOIN
JOHN A. LAMBYE, County Engineer --
WILLIAM A. JENSEN, Sup': of Building
FOR APPLICANT TO.f ILL IN Ross sr.
PESC.R E'i ON. LCT NO f_/'y, 3 OWNER
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BLOCK TRACT � ( pJ _ ADDRESS
NO OF' 8'L CGGS. -- _
SIZE OF LOT NOW ON LOT `�.'"sjt...,.�5%,v. ITY TEL.
V5 U - - _ -_- �- D75TRiCT NO. CROUP MAP PROCESSED BY
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ONTRACTOR._1, _- � - -""�i`''Gt. i»,-�• �'Y.,_'�_ _ _ e � � !�T LF
ADDRESS z � � CONNECTION DATA
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STATION tN EPT
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_ STATEOFF' R
PEGiS rRATION NU �,�y,S y,y COU NTK. MANHOLE REFERENCELOWER
NO. GESC.RIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSESEWER CONNE. T,i-4 76. Y. CURB P.L. M.L.TO P.L.
PUBLIC SEWER L $5.00
P.C.NO,
4EnT YANKSEEPAGE P.'T OR 1lOH NO. p
TS ANI ,/OR DR.AINFIELD @ S10,00 GD.-IMP_N O._____.�__--
-,
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C.aE SEWER CONNECTING .O TRUNK PERMIT NO. ROAM?PERMIT NO.
YP WALE 0I$POSAL SYSTEM 3 $3.00' _ 0
-.___._--
�fieN ECT ALt� ii0 P7.At.BLDG OR - I Ai"FtDAVITrwA1VER�-[0.Sf xEnf 7 RECORD INS R.N O. DATE ya.,
WORK TO HOJSE SEWER_.. @ S3,00
OVERFLOW SEEPAGE PI..DRAINFIELD
%TN Ce: SPGC_;Us2Y V�ELL,MAN HOLE 55..00 x
� _.-_,_-p__ HWY.OR ST.WIDCNItd G�.✓}�.�8.r}:...-...*.-.sn-43AyDON HOUSE ir� �
SEA'FR OR D 7 _@ $3. O STA'T'E ENCROACHMENT
PERMIT NO _ I
INDUSTRIA,.
-- _ - WASTE APPROVAL
CHARGES
OVVhTRR`S PERMIT - ---$ ---"2. 00 --- -- ----------—---------
_ � - CONNECTION GH A�2 GE'FEE
IT
AHORIZATION TOTAL FEE �" `` ----- __- -- _-._.-----___.--__-�- _-----___-
-i HAVE AT THIS DATE, A CONTRACT WITH THE HEREIN NAMED CON-
TREIMBURSEMENT
R.ACT'OR T'O ('O^aN ECT THE ABOVE 'DESCRIBED EXISTING DWELLING APPROVALS T�+ 7 - --- - - ---
T THE Pi:3L.0 Sx-W EP.. _-_-�YP�Rid VAlay3 —_I DATE {INSr ECTOR -1GNATURG
SICNE.D THiS OAY -
OWNER.OR NEW HOUSE SEWFFt
OWNERS AGENT__- _- _____- _ __—�- CONNE ADDIT OVAL
BUILDING OR WORK,
AODRF --__ - _ _...._._.. _.._..--....__—___.._.
s . SEPTIC TANK,SEEP.PIT(S)
I HEREBY F, K g0WLEDGE THAT HAVE READ THIS APPLICATION AND,'OR oRAINFIELD
AND STATE THAT THE. ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL I OUNTY ORDINANCES AND STATE LAWS REGULATING I I
PLUMSlNG AND 4EW ERS. Cr--SPOOL ❑. URt`W EL.L_ .❑—__ I
_ __-_-
I HEREBY CERTIFY THAT . AM PROPERLY REGISTERED AND/OR ALTER REPAIR,SEWER OR I
LICENSED AS REUU;RE.O E1'Y LOS ANGLE �!JPtiT'1' AND STATE OF SEWAGE DISPOSAL SYSTEM
ALI Of NiA OR THAI i AM TPL LEGAL OJV`v ER OF' AND INTEND TO DI CONNEfT PLUG AND T—r----- -- --
{,r li E 'N,. THE .�yE D S_R;H D RF !DEN7':AL PROP l . ABR_N__-DCNHO
HOisSE SEWER I
S!GNATU RE J _�•r,,, BACKr LL SEPTIC TANKS ❑ -�- -_t----_—
4� � ❑
OF P£RA¢i'7T E -'_---__ _., __ ..-____ flIT(51 ❑ CESSPOOLS
VALIDATION ROBERT A. WOOD
SUPERVISJNG MECHANICAL ENGINEER
CK, R¢:O. CASH
7433tg NOV 181 0 0 5»00-