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CE 808(REV.61-7B1 APPLICATION FOR PERMIT
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SEWER - SEWAGE DISPOSAL
COUNTY OF LOS ANGBES BUILDING AND.SAFETY
FOR APPLE T TO *a Q1mp MAP RSSED er
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CONNECTION DATA
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SULLDINGS STATH ENCROACHMENT
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CONTRACTOR WASTE APPROVAL
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STATELIC. RELMSURSEYENT FEE
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No. DIES C RIPTION OF WORK FELI APPROVALS DATE ITtiPECTOR'S SIONATv
HOWf BfWER CONN[C ENG TO
PUBLJC EEMIER
NIW HOW!SEWER
SEPTIC TANK,aSEPAGe PIT O!t 4w alln�
PITS AND/OR DRAMPIELD CONNECT ADDITIONAL
Hou a! R CONNKCTIN TO BURD?IG OR WORK
PRNAT�D AL EYST U
BEI-TIC TANK,SEEP,Pnl*) '
CONN ICT ADDITiO NAL 01 OR /'OR DRAINPI[Lq
WO TO HOUEa SEWER
OVERFLOW SEEPAGE PIT.DRAMPIRLD + Cl.a,.O.L❑ DRYWELL❑
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DENIER OR DIIPOSAL SYSTEM EKWAIME DULPOGAL SYSTEM
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OWNER'S
Permit a SEEP.PTf1B1 d CESSPOOLS❑
AUTHORIZATION TOTAL FEE VALIDATION
I HAVE AT THLS DATE A CONTRACT WITH THE HEREPI NAMED CON- .
TRACTOR TO CONNECT THE ASOVE D D
TO THE PU BLJC■EWER.
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OWNER OR /Y J
OWNERS AGENT # o 0 0 0 I 0
ADDRESS 00, 1•' 1 p
I HEREBY ACKNOWLl DG■ H.
AVS I HVS READ THLE APPLICATION /S r/ •� O Cl O O
AND STATE THAT THE ASOVE LS CORRECT AND'AORIE TO COMPLY (� O O 0
WITH AL1. COUNTY OI7DINAU
NC E5 AND STATE LAMB REGULATING O O O
PLUMED43 AND SEWERS. .
11,,JJCC'.',IEe HEREBY C RTIPY THAT 1 PJtDIDPP�f[R��LY_REG AND/OR n C 1 7 9
.CJLLJ PORN O NSHD AS Ye G�CM1VNlROFU ST TI RS- V U0 _
SIDE IN.THE DEfGR ED ENTLAL
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