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76A6420 ((' iI �w{,� "'�' j�� o PERMIT-.
CE 808 (REV. 6!781 d'"1P P fl.wa l c QA l I O V F H 1
COUNTY OF LOS ANGELES BUILDING AND SAFETY
ILL IN b157RICTN7 GR P 6R MAP PROCE5SEDBY
FOR APPLICANT TO PTN j "'y
ADDRESS LuI
7� 1YA1,f,,,4744 CONNECTION DATA
LOCALITY f
NEAREST STATION DEPTH 7
CROSS ST. �! d
MFe4OM' MANHOLE REFERENCE TYPE OF CONNECTION LENGTHMAIL '� ,� 7 'p Y. CURB M.L. TO PADDRESS �� 7 ✓ ;,// ?dr,:-_a
�+r`JGO. IMP. NO. JOBNO�TEL.NO t'"°j "f 2_1LEGTRUNK PERMIT NO. ROAD PERMIT
DESCRIPTIO',
BLOCK
SIZE OF LOT
LOT NO.
CITYi-rZt..ra� -TEL NO.�----_'"&.- 4'"� `� CONNECTION CHARGE FEE
�
,Lr -p
TRACT l RRr i
AFFIDAVIT WAIVER EASEMENT RECORD. INSTR. NO. DATE
NO. OF BLDGS. -
d14�
NOW ON LOT
HWY. OR ST. WIDENING -
STATE ENCROACHMENT - -
I CTSIGNATURE
PERMIT NO. - -
p�,,,y,..� A / ,...j yy
`'A""WASTE
INDUSTRIAL
APPROVAL
ADDRESS ..k'—� 6.../;2 (_) L,(j j� LACC ..f e�G"KKK"/,P
CITYi-rZt..ra� -TEL NO.�----_'"&.- 4'"� `� CONNECTION CHARGE FEE
�
STATE LIC. s°�D REIMBURSEMENT FEE
LICENSE NO. CLASS C
d14�
NO.
DESCRIPTION OF WORK FEE
APPROVALS T
I CTSIGNATURE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER
N/
NEW HOUSE SEWER
r�
-
SEPTIC -TANK SEEPAGE. PIT OR
ABANDON HOUSE SEWER
PITS AIND/OR DRAIryFIEID
BACKFILL SEPTIC TANKS ❑ -
CONNECT ADDITIONAL
BUILDING OR WORK
Qe
SEEP,PIT(S)❑ CESSPOOLS❑
HOUSE SEWER CONNECTING TO
AUTHO'RIZA`fIt,IH TOTAL FEE ,: �
SEPTIC TANK, SEEP. PITIS)
AN '0 DRAlNFIELO
PRIVATE DISPOSAL SYSTEM
CONNECT ADDITIONAL BCUG OR
WORK TO HOUSE SEWER' .......:... . .....-..
.., .
..,,
CESSPOOL C1 ORYWELL ❑
.. .,... ,
OVERFLOW SEEPAGE PIT, DRAINFIELD
EXTN., CESSPOOL, DRYW LL, MANHOLE
ALTER, REPAIR CR ABANDON HOUSE
SEWER OR DSPOSAL SYS•`I'EM
ALTER, REPAIR, SEWER OR
SEWAGE DISPOSAL SYSTEM
•- 'I- -'" "' '
DISCONNECT PLUG AND -'- - -
ABANDON HOUSE SEWER
..., .... .., >..
BACKFILL SEPTIC TANKS ❑ -
_ ..._. ...,
OWNER'S Permit S 1J
O
SEEP,PIT(S)❑ CESSPOOLS❑
AUTHO'RIZA`fIt,IH TOTAL FEE ,: �
- VALIDATION
IS E A CONTRACT WITH THE HE NAMED CON-
STI
HAVE AT FIC
E DESCRIBED EXISTING DWELLING
TRACTOR TO CONNECT THE ABOVE
� ¢a +� � 'ad "
T07HE UBLI 5EW
SIGNEDTHIS.M DAY OF
T_
OWNER OR. . Yir' �"p/p ✓ ...a:,y
OWNERS AGENT c.._�.., -..,
ADDRESS.
1 HEREBY ACKNOWLEDGE THAT I' HAVE READ THIS APPLICATION
- _.
(h 6 1 p t
r
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
-
PLUMBING AND SEWERS. i. . ., ..
.,. _.. ..., .... ..
.. .. .. ... -
I HEREBY CERTIFY THAT I'AM PROPERLY REGISTERED AND/OR
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO RE-
SIDE IN, THE ABOVE DESCRIBE] RESIDENTI PROPERTY. _
SIGNATURE
OF PERMITTEE"
' .. ,. <,:.. „,„.«..,.U.,:.,.,w., w...,..�„m.. <�.s+�”�ro�::.�•g�,......,a...,.:..a.:..,..,.•..�...,.,..,....�.,.��rnam.,�.,s.wows.F++wwu��...,.«..«..�..»a...:...e..®,.,..,.-..�..e....,F.»«.,,.,.,.,,......:.._....
`gig
OTiOUOG'1E14L INFORMATION'
.�,
t. INDICATE ALL BUILDINGS ON PROPERTY.;;-
._..,
2. INDICATE AND DIMENSION SEWAGE DISPOSAL
SYSTEM WITH TIE DISTANCES TO BUILDINGS
AND PROPERTY LINES. m.
3. INDICATE SIZE 'OF SEPTIC TANK-DEPTH OF SEEP-
AGE PITISI - SIZE OF CESSPOOL(S).
4. INDICATE NORTH DIRECTION ON PLOT.
5. INDICATE BOTH STREETS IF CORNER.
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FIELD NOTES
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