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6A&42Q°-�3 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADORE SS s ,;,... 4 v z'L 'y�y✓' 7 9 L=-�,A,- �, _
JOHN A. LAMBdE, County Engineer --,,z �- -- ------
WILLIAM A. JENSEN, S p't of Building
LOCALITY -__SF - ..--_ - --.-.-._-
NEAR 'T
FOR APPLICANT TO FILL IN CROSS ST ___
DESCRIF TIOf�-'� LOT NO r3 ', /',.� _ ti.: OWNER -._.._
MAIL
BLOCK 'i RAr'T � k (j, ADORES S
_
u fi
NO. OF BLDGS.
SIZE OF LOT NOW ON LOT-- CITY TEL. NO,
USE C�
BUILDINGS D_�TR;..7 NO CROUP MAP PROCESSED BY
BK PG
Z-"
ADDRESS ;' -- CONNECTION DATA
STATION DEPTH
,
- ❑ STATE tSPPER
REGISTRATION NO. fy COUNTY MANN OLE REFERENCE LOWER.
NO. FEE TYPE OF CONNECTION LENGTH FROM
j1-�O S S KAP CONNED TNG 7d Y. CURB P.L. M.L.TO P.L. .�
PUBLIC SSEWER $5.00
P Y-.....___ _- ._._. ,C NO -_-..--_�_
--j FFT;C TAN £
SE%A'E PtT' dR---- - CO IMP NO. JOB NO
I PITS AND f N.DRAI.NFIELD $9D.00 _-_,-.--.-._.-
-r4
40SE SDIS SAL SCONNYSTEM 'TO TRUNK PERMIT NO. ROAD PERMIT NO.
PIVA''E DISPOSAL SYSTEM @ $:3.00 �' G$°.
CONNECT ADDITIONAL SLOG.OR .AFFIDAVITI wAiVfR IFAS EMEItTT RECORD.INSTR. NO. i DATE
WORK TCO HOUSE SfKER @ 33.CU
- ��OVERFL O4V EEPAGE PiT,DRAIN FIELD
.r_S$POOL,DRYK'ELL,MANFIOLE & $3..00 yam,
--r- _- - -_-_ _- --_ HW Y.OR ST.WIDENING
i ALTER. _ 9tl HOUSE
1 ,P L13
EWERYSTEM
-_ -_ PERMIT NO.
-
INDUSTRIAL
WASTE APPROVAL _
CHARGES
TSL :R'SS �y _PERMIT p $ 2 00 -------- ------------- --------------
A61HORIZAdION TOTAL FE --__ L -� CONNECTION CHARGE F'EE ---- ---Y�—-----—
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRtB9D EXiS'J NG DWELLING --- —�-j--X97[---- --- ---- -- -- -- -
TO THE PUBLIC 5FWEf' 3✓.�'. - APPRO`PALS DATE i INSPECTOR'S SIGNATURE.
SIGNED THIS DAY OF_ _,_ "'.✓ I9.�` --- — --- �— ---�— — -
OWNER OR NEW HOUSE SEWER I OWNERS CONNECT ADDITIONAL �—
BUILDING OR WORK
K,'TFEP,PIT(5)S) —}-
SEPTIC TANSEE — 1----�—_---------i�
I HEREBY AC:KNOWI.EOGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
W1.0ALL COLI NTY ORDINANCES AND STATE LAWS REGULA.TiNG —
PLUM'iING AND SEWERS. CESSPOOL DRYW ELL
-- ---J.--. — -- - - '-
r
HEREBY CERTIFY THAT i AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSED AS REOU FRED BY LOS ANGLES AND STATE OF SEWAGE DISPOSAL.SYSTEM r
Ch L)FORN,A. OR THAT 1 AM THE LEGAL OWNER OF, AND IWEND TO DISCONhI CT PLUG AN
RE_5'iGE IN, THE .A.CiOVE DESCRIBED RF_51 ;*T1AL. PROP'6Y, ABANDON HOUSE EWER
SiGNATURE ✓` = �+
r s �
T ` _-�- �.'_ ?�"' i - . BACKFILL SEPTIC TANKS F2OF PERMIT
-- .SEEP.P17 S) CESSPOOLS [t'I
-vALIDATION ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
CK. M.O.. CASH -
vL qq
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o'A842D APPLICATION FOR PERK
COUNTY OF LOS ANGELES SEWER—SEWAGE, DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION 51)iLO'ING
ADDRESS
JOIN A. LAMBIE, County Engineer —
WILLIAM A. JENSEN. Supt of Building
LOCALITY
FOR APPLICANT TO FILL IN -Foss ST.
LEGAL �.:....
D F_SCRIRT'ION LOT NO. OWNER h
MAIL
BLOCK TRACT- ADDRESS -
NO. OF BLDGS, -
SIZE OF LOT NOW ON LOT CIT':' TEL_, NO,
U%E OF
BUILDINGS - DISTRICT NO. GROUP MAP +,RO Esq,`
K PG yl?�Y'
CONTRACTOR
- Y °
ADDRESS CONNECTION DATA
CITY TEL NO. -_ -_ —_-_ STATtO 'J ,F JQ DEP }{_�
STATE MANHOLE REFER C=''' J1 y £'-
REGISTRATIQN NO COU NTY
NO. 1 DESCRIPTION OP WORK ._._FEE - _ TYPE OFC N'EC'IxJON � p, LEN uTti FRONT
-_.T}i4U 5E:5EW R CONNED TI Nr3 TO - Y. CU i3$- P L. M-L TO P.L. .
PUS FC CEWER Co) F$5.Q0 i L �;' .__- =_ __ C-.-.NO
_._
_. O
SEPTIC FITS AND,NK'OR DRAINSEEPAr EE PDT CJ P. @ $1000 I CO IMP NO,
,.. JOB Nti7
}iOUSE SEWER CONNECTINGTO PERM4
ITP
-�PRIVATE DISPOSAL SYSTEM _-_ L $3.00 TRUNK PERMIT NO. ROAD
_ __ -_. _-...—� ._-.. _—. _ _._ST
CONNECT ADDITIONAL BLDG..OR gFFiDAV IT I $'AtYEk E45EMEWT .RECORD.INSTR NO. DA7F_l Jf
TO HOU &E SEWER @ 43.00 I �_-_.
OVERFLOW SEEPAGE PI CRAINFIE-LO
EXT .GBSSPOGELL.MAOLE $3.-Oq
ALTER.REA RORAEANDON HOUSE I i
_HWY. OR S_7.�._WIDENING
-_
EW E_R OP DISPOSAL SYSTEM ' $3.00 STATEENCROACHMENT
PERIM NO. -
__.�_.-____ INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNER'S PERMIT $! 2 Qo -- — -- — — — ---- — -
,_.....—.�_,__ CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE _ �g ? -------.------ -----
-_ j REIMBURSEMENT FEE
I HAVE A7 THIS DAVE A. CONTRACT WITH THE HEREIN FARMED CON- -- --------------
TRACTOR TO CONNECT THE.ABOVE DESCRIBED EXISTING DWELLING -------- ------t-r- r-- ---- --- ----- ------- -------
TO
7HE PUBL1.. SEWER. APPROYALJ -DnFE 11ta5PECTOR SSIG NATL!RE
SI G N E.D TH I S-._ DAY OF-
OWNER
F-OWNER OR NEW HOUSE SEWER
OWNERSAGENT—____
- ADDITIONAL_.
CONNECT ADDITIONAL -
BUILDING OR WORK
SEPTIC TANK,SE EP,F ITIS)
I !- CESY ACKNOWLEDGE THAT i HAVE READ THIS APPLiCATION AND/OR DRAINFIELD
AND STATE THATTHE ABGVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCE AND STATE LAWS REGULATING
P L.UM,INC- AND SEWERS. CESSPOOL ❑ DRYWEI_L CJ
FIERE BY CER IFY THAT I AM PROPERLY REGISTERED AND'OR ALTER.REPAIR.SEWER OR 1
LICENSED AS REQ}ITED BY LOS ANGLE- COUNTY AND STATE OF SEWAGE DISPOSAL YST'F_.M
CAIIFORNIA OR THAT 1 AM THE LE:GAL OWNER Or`, AND INTEND T6
RESIDE IN, Tlic ABOVE LFC'_RIeED REE-(D ..
.EN., L PROPERTY. DISCONNECT PES AND
ABANDON HOUSE
SEWER I
SIGNATURE
OF PERMRT.Ec ' BACKFILL SEPTIC TANKS [r �
SEEP.PITIS) t_I CESSPOOLS
VALIDATION ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
CK. M.O. fASH.j