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APPLICATION FOR PERMIT 1
DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL
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LEGAL
DISCRIPTION LOT NO 07nHR
BLOCK TRACT MAIL
ADDRESS
I N0. OF BLD BS.
SIZE OF LAT X I KNOW On LOT CITY TIL.MO.
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COMTRACTO
ADDRESS' COHI'�.GTION DATA
CITY TEL. STATION DEPTH74
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REFERENCE / UPPER
REGISTRATION NO. rl
No. DESCRIPTION OF WORK r EE
HOUSE SEWER CONNECTING 70 NECTION LENGTH FROM Q
CUR P. Y.L.TO P.L.
PUBLIC SEWER S.SO
HOUSE SEWER CONNECTIN TO
PRIVATE DI POSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG. OR P. C. NO.
WORK TO HOUSE SEWER 1.00N0. JOE NO.
ALTER OR REPAIR ISYS E RMIT NO. ROAD PERMIT NO.
SEWER OR DISPOSAL SYSTEM 1.60
DISCONNECT AND ABANDON SEWER CROACHMENT
AND/OR DISPOSAL SYSTEM 1.00O.
SE C TANK,SEEPAGE PIT OR
PITS AMD/OR DRAINFIELD .00AL
CESSPOOL- DRYWELL M PP V L
SPECIAL CONDITIONS ONLY 1.00 CH
CONNECTION CH E
Off'$ PEBMIf $ 1 00
AUTSORTLATION TOTAL FEE REIMBURSEMENT FEE
I HAVE THIS DATE CONTRACTED WITH THE HEREIN PLAYED CON-
TRACTOR TO CONNEC"[ THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSP R'S SIGMATUQH
TO THE PUBLIC SEWER
SIGNED THISZ#_DAY OF 1 NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL .
OWNERS AGH 12
BUILDING OR WORK
ADDRESS_ SEPTIC TANK,SEEP, PIT(S)
AND/OR DRAINFIE:LD
I HEREBY ACKNOWLEDGE THAT I HAVE RE,6 THIS APPLICATION CESSPOOLS DRYWELL C]
AND STATE THAT THE ABOVE IS CORRECT AND AGREX TO COMPLY
WITH ALL COUNTY ORDINANCES AMD STATE LAWS REGULATING ALTFR REPAIR.SEWER OR
PLUMBING AND SQWERS. SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT I AY PROPERLY REGISTILERM AND/OR
PCENSED AS MMOUIRED BY L%ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT 1 AY THE LEGAL OWM OF THE ABOVE ABANDON HOUSE SEWER
DESCMIDEMAEfID O BACKFILL f C TAKNICS❑'
SEEP. PIT f CESSPOOL)
OF PERMITT[!<
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