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16A64 20 APPLICATION FOR PERMIT
>a"A64
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BIJILDING AND SAFETY DIVISION BUILDING ✓ �� �
TORN A. LAMBIE, County Engineer ADDRESS' «
WILLIAM A. I'ENSE.N, Sunt of Building
LOCALITY .._. .. _ ..
FOR APPLICANT TO FILL IN
CROSS ST. , ;
OE5C RIPTLOP{ ::OT N.O. OWN E62
MAIL
BLOCK TRAC7 ADDRESS ..
NO. OF BLDGS. -
512E OF LOT NOW ON LOT CITY TEI. NO
USE OF
SUILDINGB DISTRICT h1 b. GROUP MAPri OC: 'ED By
HK PG
CONTRACTOR -
ADDRESS
CONNECTION DATA
DATA
CITY
MANHOLE REFERENCE ,
*-- Y. _ -_- TEL NO_-'� -_ '_- 5 ATION DEPTH ,£
REG;S F2ATPON. O �� ` L�..�5TATE
COUNTY
6F'
�F.SCR PTfGN YYORK FEE - _
__ TYPE OF COONNEC7d'ON LENGTH FROM _
— —
HOUSE SF WER uONNECTING TO rr Y. S,Lif g,.° ': P L - }A.L TO P.L.
L U �..
PF89
N f H LC'SEWER @ $5 00 _a.�=-L -,-- P C.NO.
SEPTICTANK EFPAGE Pi T' OR CO. IMP.NO:. ! �+ JOB NO.,
r T5 AND OR DPAINr'IF I D $10.00
_--
HOUSE 1,EINIER CONN 1'NG i O - I TRUNK PERMIT NO. ROAD PERMIT NO.
F F ✓ T_DjSPOSAL SYSTEM- @ $9.00
I D7 .O^eF BL.I.G OR - ��- AFFiUAYI I i NA!vER Ek`a€NEWT RECORD.INSTR. YVO PATE ---
J✓)H K I'()HV 0 S F SLWER $3.00
OVERFLOW S�_PAGE.PIT,DRAINFIELD
EXTN.CE SSP 00'e..,ORY WELL.MANHOLE @ $5.00 i. HWY. OR ST.WIDENING
j ALTER.REPAIR OR ABANDON HOUSE r - �—
SEWERORDISPOSALSYSTTEM @ $3.00 __—___
5TA.E:ENCROACHMENT
PERMIT NO.
--- INDUSTRIAL
i WASTE APPROVAL.
CHARGES
OWNER'S PERMIT 2; ®o _ _ _
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL. FEE
1 HAVE AT THIS DATE A CONTRACT WITHTHE HETMT
REIN NAMED CON- REBUR5EMENFEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO 'rHE PUBL.0 SEWER. APPROVALS DATE. INSPECTOR SIGNATURE
SIGNED THIS-—DAY Oe--__.----__-_----_._rs_
OIVNER OR _ NEW HOUSE SEWER -
OWNERS.AGENT-___-_— _._ -- CONNECT ADDITIONAL _-- _.__— —._—_--�--- -----
BUILDING OR WORK
ADDRESS
I HER VY ACKNOWLEDGE THAT I HAVE, REALS THIS APPL:iCATION !
AND STATE" THAT THE ABOVE IS CORRF_CT AND AGREECOMPLY
TO ANDi JH DPArNFIELD
WITH. ALL COUNTY ORDINANCES AND STATE. LAWS REGL'LATTNG I
PLUM 6ING AND SEWERS. CESSPOOL ❑ DRYWELL_
i HEREBY CERTIFY THAT 7 AIM PROPERLY REGISTERED ANDInR. ALTER,REPAIR.SEWER OR
7 Si-FNSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM f
A L:PO.RNIA OR THAT I AM THE LEGAL. OWNER OF.. AND INTEND 7O _._—
D75CONNECT PLUG AND
R 5-iD . IN, THE AB \ DESCRIBED RESIDENTIAL PROPERTY. ABANDON HOUSE SEWER
SIGNATURE
PERMITTEE �w-,� BACKPILL SEPTIC TANKS
?F - _ _ z +' fw
--- SEEP,PIT(5) i� CESSPOOLS
VALIIDATION.. ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
CK. M.O. CASH
t J i
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:E9GB 3_62 APPLICATION' FOR PERMIT
5A642D
COUNTY OF LOS ANGELES SEWER-SEWAGE IDISPOSA�.
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A, LAMBIE, County Engineer ADDRESS t? � —' � � -V :e -— -
WILLIAM A. JENSEN, Supt of Building — -
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CRDbS ST. �
r
SSE SC R I Y7 ION L O7 NO OWNER
.__`__ -1 ._. �..x.
MAIL
BLOCK TRACT :-j." ADD RE53.,�
1
-y r3 w NO. OF BL.L GS. q -.
Siff OF, [-or ! y' NOW ON G_07 ccry ML. NO. .
USE OT' _
EU I L.DINGS -.._,Q DISTRICT NO. GROUP MAP PROCESS€D BY
BK PG
CONTRACTOR
ADDRESS A CONNECTION DATA
CITY a ,4 ,r TEL NO..!- •-- I P. All ON 1 DEPTH P'F7
(x'y STTE MANHOLE REFERENCE
NCE _..
REGISTRATFON NO j {.OUNTY j ri �'-�,
NO. DESCRIPTiON OF WORK FEE - _. -
TYPE OF CON NE�7fa^i,N - LENGTH FROM
HOl SE SEWER Co NNELTiNG TO I Y. ACU y - Px1.. M.L.10 P.L. Q6
PU HL.IC SEWER 85.OG - _— —,• t ?'-+--. "_.—,——___� _,-._�._____ 614d'
_—
PC.NO.
SEPTdG.TANK EE PAC6 P;T OR I CO.IMP NO. JOB No.
PITS S AND/OR DR A:N1�lF.LES � $iO.OD -
i
HOUSE SEWER C ONNEC_T7N.<---TO -"— —-- —_
PRIVATE DOSALYSTEM @ $9 GG - --- ---_- TRUNK PERMIT NO. t ROAD P.z.'RM17 NO. pri0'� 1
CONNECT ADDITIONAL BLDG.OR I rFFI --'--- --._iD.A VlT_r _..
WAI YLR RECORD.INSTR No, DATE
I WORK 70 HOUSESEWER @ $3.00 I i ''
_._.— _._ __.. _-.
OV ERFLO'N SEEi'A tVE PiT,DuAiNFiELD
'FXTN::;F.SSn00`,_.,ORY VdrE L:t.MANHOLE @ $5.00
_— _ HWY.Oft T WIDENING i.
ALTER.REPAIR OR�!, S't aT 14 HOUSE ,m
E.1hq.OR DFS"> bYSTf.M STATE.ENCROACHMENT _.
'� P a1 9• PERM I NO.
INDUSTRIAL
if
j WASTE APPROVAL
OVMER7S PERMIT $ L_ }''"
—T CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE - --- -____ ------------- ----___ __...
HAVE AT 'THIS ;TATE A CONTRAC' WITH THE: HEREIN NAMED CON. REIMBURSEMENT FFEE
7RACTGR r0
1-0,"N ECT THE .ABOVE DESCRIBED EXISTING DWELLING ----- �y Y - -
TO THESFYJE R.
APPROVALS DATE NSPECTOR&SFG NATt/RE.
SIGNED THIS_ .DAY' O F -- �------19—.__ --'- ---- - —.�—. ---�-- --�--} ---- -'---------
OWN"ORA E ry, _ NE
LW HOUSSEWER
O'NNR3 AGE NF CONNECT ADDITIONAL
BUILD NG OR WORK
SEPTIC TANK SF.F PiTtS1
Y {; RFF,V Al Kh7GWLECJ Ca THAT I HAVE ft F'A1J 7HI:5 AFh'L! A710N AND OR DRAINF F'I.D
AN n 9fAt'L THAI THE. ACiOYw 49 GOP:RECT AND ASi RE[; TG ..OMRLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL. Q CRYWELL Q j
Ht 3CSYCERTIFY THAT ! AM PROPERLY RF.GFSTERED AND/OR ALTER•REPAIR,SEWER OR !
LI+';ENSED. AS REQUIRED OY LOS ANGLES. COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CA'_(FORWA, OR SHAT 1 AM THE LEGAL O'NNER OF, AND INTEND TO
j
RESIDE N, T'H ABOVE D 5CRF£sED RESIDENTIAL PROPERTY. DISCONNECT PLUG AND
ABANDON HOUSE SEWER '
SIGNATURE
OF PERM BACKFILL.SEPTIC ANK5 []
OF PERMITTEE _ - _. __ ._ _.___—_.__._ SEEP.PIT 1,S) [_I CESSPOOLS Q! !
VALMATION-- ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER,
CK. M.O. CASH