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APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION ADDRESS d L G
JOHN A. LAMM County Eaginwor G.
CASSATP D GBnTM, St t of B.Ddiap LOCALITY
FOR APPLICANT TO FELL IN : NEAREST
CR059 9T
LEGAL ✓J
DESCRIPTION LOT RO OWNS A/
BLOCK TRACTMAIL
W ADDRESS
FB !
SIZE OF LOT CITY TEL NO
USE OF
BUILDING DISTRICT NO GROUP MAP P ESSn
CONTRACTOR % -Z °R %
ADDRESS/6 �. I CONNECTION DATA
CITY TEL NO jLg �Ayf&O A ON DEPTH
STATE MANHOLEREFERENCE , PP
REG STRATTON NO 0 COUXT7 i
M
No DESCRIPTION OF WORK FEE
HOULE SEWERSCEOENNECTING TO ff 00
SFTICT NKOR O AI A EDIT OR $3 CIO
T TYPE OF CCTIOR
CURBPL Y LGTXPROr
OVERFLOW SEEPAGE PIT DRAINFIELD -
EXTN CESSPOOL DRY.IE'LL MANHOLE 200
HOUSE SEWER CONNECTING TOP C NO
PRIVATE DISPOSAL SYSTEM $I DO CO IMP NO JOB NO
CONNECT ADDITIONAL BLDG OR TRUNK PERMIT NO ROAD PERMIT NO
WORK TO HOUSE SEW BR 1 00
ALT R ggEPAIR OR ABANDON HOUSE STATE ENCROACHMENT
8 R OR DISPOSAL SYSTEM 1 00 PERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
Owr4m PERMIT f 2 100 CONNECTION CHARGE FEE
ADTHORPLATION TOTAL FEE REIMBURSEMENT In J1 (=PZ-
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON APPROVALS DATE INSPECTOR l91GNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER
SIGNED THIS DAY OF IB_ NEW HOUSE SlW[R
OWNER ORE /,!/ CONNECT ADDITIONAL
OWNERS AGENT 'r BUILDING OR WORK
SEPTICTANK EP
ADDRESS AMD OR DRAINFEELD PITADDRESS
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL 0 DRTWELL
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED ARD/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AN THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDER PROPERTY BACKFILL SEPTIC TANKS❑
S18NATURB S PITS CESSPo
OF PERYI
mP V2{L,2 a �� RNG MECH WOOD
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