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76A642L APPLICATION FOR PERMIT
76 A64
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS 5T
LEGAL
DESCRIPTION LOT NO /� OWNER
BLOCK TRACT 4 7 LS MAIL
ADDRESS
NO OF BLDGS
SIZE OF LOT NOW ON LOT CITY EL NO
USE OF
BUILDINGS t-- "V DISTRICT NO GROUP MAP ROC E S SED BY
[� BK P
CONTRACTOR
J�Qp rCJ7
3 r
ADDRESS CONNECTION DATA
CITY TEL NO 3 STATION DEPTH
STATE LIC UPPER
LICENSE NO CLASS MANHOLE REFERENCE LOWER
NO DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y CURB PL ML TOPIL
PUBLIC SEWER PC NO
SEPTIC TANK SEEPAGE PIT OR JOB NO d
PITS ANDlOR DRAINFIELD CO IMP NO O
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO V
PRIVATE DISPOSAL SYSTEM C9
CONNECT ADDITIONAL BLDG OR S� AFFIDAVIT wMll I [.SEM[KT RECORD INSTR NO DATE O
WORK TO HOUSE SEWER
OVERFLOW SEEPAGE PIT DRAINFIELD u
EXTN CESSPOOL DRYWELL MANHOLE @ W
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING a
SEWER OR DISPOSAL SYSTEM @ STATE ENCROACHMENT N
PERMIT NO z
INDUSTRIAL
WASTE APPROVAL
OWNER S PERMIT s �� CHARGES
AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEE
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER APPROVALS DATE INSPECTOR S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR - NEW HOUSE SEWER
OWNERS AGENT
CONNECT ADDITIONAL
ADDRESS , BUILDING OR WORK
SEPTIC TANK SEEP PIT(5)
I HEREBY ACKNOWLE THAT I HAVE REA THIS APPLICATION /
AND/OR DRAINFIELD ✓/
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
LICENSEDAS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF AND INTEND TO DISCONNECT PLUG AND
RESIDE IN THE ABOVE DESCRIBED RESIDENTIAL PROPERTY ABANDON HOUSE SEWER
SIGNATURE Cl
PERMfTTEE BACKFILL SEPTIC TANKS
SEEP PI71S) CESSPOOLS ❑
VALIDATION
CK M 0 CASH4/
7 2 1�r_-MAY 31.1 (b 0 9 0 0 o:b