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7eA642p APPLICATION FOR PE MIT
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COUNTY OF LOU ANGELES SEWER-SEW GE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION Bu 1LDIN0
JOIIN A LAIIHIF C...tY Fogmror ADDRESS
COLE MAN 9; JF NAINS sup of Building
LOCAL TY
NCARE8T
FOR APPLICANT T FILL cnoae Br
LEGAL
DESCRIPTION LOT OWNER
MAIL
BLOCK TRACT ADDRESS
NO OF SLOGS
SIZE OF LOTj NOW ON LOT CITY TEL NO
US! OF pISTRICT NO GROUP MAP PROCCit Y(
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ON PO
CONTRACT R ]( C
AO CB > �/. LLJJ CONNECTION DATA
&.&L
Y TEL ST'S DEPTH
LI N LICENSE UPPER
NO 2 CLASS MAN OLE REFERENCE
L
NO DESCRIPTION OF WORK FEETHOP CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y CURB PL ML To PL
PUBLIC SEWER @ $ D 00
OTTSEEPAGEPITOR
PC ry0
PITS AND/OR GRAINFIELD IT $10 00A:3 ,
CO IMP NO JOS HO O
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD QRMIT NO V
PRIVATE DISPOSAL SYSTEM P $ 3 00
CONNECT ADDITIONAL BLDG OR AFFIDAVIT RMYU tAt(P(ET R CO INSTR NO DAT[
WORK TO HOUSE SEWER Q $ 3 00 O
SEWER OR DISPOSAL SYSTFM Q $ 3 00 1{rYJ
LOW SEEPAGE P11 uNAINriELu HWY QRST WIDENING D.
CETN CESSPOOL MANYOLE P f S 00 US
STATE ENCROACHMENT
PERCOLATION TEST P $ D 00 PERMIT NO
INDUSTRIAL
WASTE APPROVAL
OWNER'S PERMIT s z o0 CHARGES
AUTHORIZATION I TOTAL FEE Q CONNECTION CHARGE FEC
1 NAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CNN REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED APPROVALS
TO THE PUBLIC SEWER DATE INSPECTOR S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWN[RAl
t AGENT
CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
SEPTIC TANK SEH, PIT( 1 J
1 HERESY ACKNO E 6 THAT I HAVE READ THIS APPLICATION A O
AMO STATE THAT T ABOVE li CORRECT AND AOR[[ TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ❑
PLUMBING AND SEWERS CESSPOOL ❑ ORYWCLL
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED ANO/OR ALTER REPAIR SEWER OR
LICENSED AS RED U IR[D BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I M TH6 LE L WN6R 01 AND INTEND TO DISCONNECT PLUG AND
-------
:E..-. IN THE:Ae 6.THEL HEN POPOV"ERY ♦SAry00X HOUSE UGSEWER
AND
IO NATURE
OF PERMITTEE BACKFILL SEPTIC TANKS ❑
SEEP PIT(S) ❑ CESSPOOLS
0 VALIDATION
C M 0 CASH
LAWl 3 6 2� AU625 I O D 1 5.00-
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