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aCE800A 4/72 APPLICATION OR PERMIT
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COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL.
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION eI.R�SGq
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FOR APPLICANT TO FILL IN =
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DESCRIPTION LOT NO, �'�} .J BLOCS TRACT1-5 L> AI NO, OFBLDGS, �jy^SIZE OF LOT NWON LOT C ' (_�/ EL. NO. �S / S'
USE OF BISTRICTND. GROUP MAP ESSED BY
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CONTRACTOR
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ADDRESS C). If9n 0-Y 12- 6 CONNECTION DATA
CITY 7�f/� , If TEL. NO, '1 s STATION DEPTH
STATE LIC v
UPPER
PER(� Z MANHOLE REFERENCE
LICENSE NO. T ( CLg55 / LOWER
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTIONENGTH FR M
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P. r
PUBLIC SEWER co
SEPTIC IANK,SEEPAGE PIT OR P.C.NO. /1 �I O
PITS ANO/Oft DRAINFIELD CO.IMP. NO. JOB N. J ✓/
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. V
CONNTE DISPOSAL SYSTEM 0
CONNEC DISPOSALA00ITIONAIL SYSTEM OR AFFIDAVIT W[IVER [XSEX[Xi RECORD.INSTR.NO. GATE O
WORK TO HOUSE SEWER @ F
OVERFLOW SEEPAGE PIT,GRAINFIELD
E%TN,.CESSPOOL.ORYWELL.MgNHOLE
ALTER. REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING N
SEWER OR DISPOSAL SYSTEM STATE ENCROACHMENT Z_
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT s
CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE
HAVE AT THISDATE A CONTRACT WITH THE HEREIN NA IEO CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS
TO THE PUBLIC SEWER. DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF-19—
OWNER
F 19_OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL �f1
BUILDING OR WORK
ADDRESS
SEPTIC TANKSEEP.PT(S)I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR GRAINFIELD
ANO STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
FLU NO ING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT AM Pfl OPER REGISTERED ANO/OR ALTER, REPAIR,SEWER OR
LICENSED AS REO RED B OS ANGLES C NTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR TH A E LEGAL OWNE OF FANO INTEND TO
RESIDE IN, THE AB E E�4CRIB RESIDENT/ PROPERTY, DISCONNECT PWG ANO
/ / ABANDON CT SE PILU SEWER
SIGNATURE
SIGNATURE
OF PERMITTEE BACKFILL SIC TANKS
SEEP.PIT I51) ❑ CESSPOOLS ❑
ALIDATION
CN. 'A.0. CASH
y OF 'r J&S CONIPENSAT
POLICY HOLDER:O 1 4 2 i.,'41 �-O 1 v D 1 4.0 O 6
POLICY NUMBER: