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642D 2/70 PERMIT ,FO.�-1SEWER
75A
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COUNTY OF LOS ANGELES SEWAGEDISPOSAL
DEPARTMENT OF COUNTY ENGINEER h
BUILDING AND SAFETY DIVISION uILOING !'...,i ;,\�!,` �.;t
JOHN A.LAMSIE.COUNTY ENGINKIER A...... r...a<� .J:r -- ✓
COLEMAN W.JENKINS.SU►'T.OF BUILDINGLOCALITY
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OR' PPLICANT TO FILL IN NEARESS ~
,PRINT OR TYPE ONLY) CROs6 T.
DESCRIPTION LOT NO. OWNER
MAIL 1
TRACT ADDRESS i
NO.OP BLDOY.
F LOT - NOW ON LOT CITY T[l.DISTRICT NO. GROVP CLA59 Ap PROCfSEEDSY
NGS8K PSACTOR Ies s t C.C] "1.Lt- r..�; L _st'� CONNECTION DATA...~..1�.\'tiL�\14I • TEL.NO. STATION . OEPTN
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n� 2iCl.. +/A-% MANHOLE REFERENCEE NO.DESCRIPTION OF WORK FCC TYPE OF CONNECTION LENGTH FROMOUSE S1WER CONNECTING TO Y. CUR[ P.L. M.L.TO P.L.UBLIC S[WEREPTIC TANK.SEEPAGE PIT 011
FIT.ANO/OR DRAINFIELD tE .1000 CO.IMP.NO. JOE NO. �'
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.� / • I{
PRIVATE DISPOSAL SYSTEM li 63.G0 / / d
CONADDITIONAL L.G.BOR FFIDA VIT RMvvx lAf lRvx RECORD.INSTR.NO. GATE
0'
WORK
TO TO HOUSE SFWER � f3.00 V
OVERFLOW SEEPAGE PIT.GRAINFIELD W
E-N..CEBSPOOL.DRYWELL.MANHOLE tE BS GO
rAUTHORIZATION
-1AIR OR FlANDON HOUSC HWY.OR Sr.WIDENING W
R DISPOSAL SYSTEM $300 -STATE ENCR OACHMENTPR >INDUSTRIAL.p WASTE APPROVALM'S PERMIT It 2 00 CHARGESO t
TOTAL FEE11 CONNECTION CHARGE FEE IS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING BRAD CONDITIONS BELOW I
TO THE PUBLIC SEWER.
SIGNED THIS DAV OF 19—
OWNER OR THIS FORM WHEN PROPERLY MACHINE V___ -
OWNERS AGENT DATED BELOW IS A PERMIT TO DO THE WORK
DESCRIBED. I
ADORES. l
I HERESY ACKNOWLEDGC THAT I HAVE READ THIS APPLICATION Permittee is hereby authorised to install the work f
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY gg_���wn, in aCCOtdaRCe with provisions of Ordin- p
WITH ALL cou Nrr osDln ANees AND STATE LAWS REGULATING anc-2 2269 and related Ordinances.
PLUMBING AND SEW ERS.
IHERESY CERTIFY THAT I AM PROPERLY•'REGISTEREO AND/OR This permit become.null and void if Work is not cam.
LICE NS.ED Ae REQUIRED ■Y LOS Ne LES XOEINTY AND STATE OF menced Within 60 days from date of issuance,
CALIFORNIA OR THAT I AM THELE L OF.AND INTEND TO Or If work is suspended at any hms daring COn-
51GNARCSI. IN. THf•�fOVt DE{¢RI[ R[fl TsIA'L'PR+OP{RTY. ■traction for a period of 126 day[.Or if any work is
sl or AvRb�ArrrEE�� '�"-� 1 �+L�'��. done on the said building or structure in violation of
ACounty Ordinan e o tat laws .-sari
VALIDATION JACK R.ALLEN II
.CK. M.O. CASH SUPERVISING MECHANICAL ENGINEER t
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