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7ewe42D APPLICATION FOR PE MIT
EL
COF LOS TY ENSIl�E SEWER—SEWAGE DISPOSAL:.
DEPAETTNUMEM NY OF COUNTY ENG
BUILDING AND SAFETY DIVISION BUILDING 4
JOHN A. T AMM Co=ty Ea ADORE"
W UJJ" ti IENSM. Sup'[ of �ldby
LQCA LTTY
FOR APPLIC TO IN r1E,REfT �` '
CROSS er
� S [
DESCRIPTION LOT NO. • OW N[R
MAIL [
BLOCK TRACT f 0 ADDR "y
NO. OF BLDOB. '
SIZE OF LOT RbW ON LOT f�rA
TEL. No.
eu LD naB No, brtouP MAP ■nlE or
- MY
■K
coNTMCToR ADDRESSCITY TEL. NO. DEPTH�e E RR[RE NC[REOISTRwTION HO, ryNO. DESCRIPTION OF WORK FEEE OFC I N LEND FROM00
HOU■E SEWER CONNIEC-nN0 TO CUR■ F.L M.L. P.LPUBLIC SEWER 0 .8.00B DTIC ANK,■ GEP OR F.C.NO.
FIT;AHD/ORDRAINFI[LD * .10.00NO. JOE NO.
HOUBE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT
PRIVATE DISPOSAL SYSTEM * .9.00
CONNECT ADDITIONAL BLDU.OR FH
AVIT SAfYI[ w[SQT RECORD.RD.INSTR.N . DA •_
WORK TO HOU.[BEWER a 59.00
OVERFLOW■EVAQE PIT,DRAINFIELD
EXTN.,CES;FOOL DRYWElL MAN HOLE Q .8.00
ALTER.REPAIR OR ARAND OR ST,WID[HI1�G
;EWER OR DISPOSAL SY;TEM 7.00 [NCRO,CHMENT
IT NO.TRIAL APPROVAL
CHARGES
owrrF.I�s r�al+�r s 200AUTHOBMTION =OVAL FM ECTION CHARGE FE;I HAVE AT THIS DATE A CONTRACT WITH THE REREIN N yED CON. URSEMENTFEETRACTORTO CONNECT THS ABOVE DESCRIBED LXIfTING DWILLINOTO THE 1. LIC SEVER. APPROVALS 'rI INOKCTOI?41 TUR[
SIGNED THIS DAY OR IDOWN"QROU.[■[W[ROWN[RQ AGENT ECT ADDITIONAL
ADDRESr ING OR WORK
14EREBYACKNOWLEDGE THAT I HAVE READ THIS APPLICATIONC TANK,B[[P,FIT(f)
AND STAT[ THAT THE ABOVE Id CORRECT AND AGREETo COMPLY R D{tA1HK1[LD
WITFI ALL COUNTY QIIDINANCKA /IND I<TATE LAWS REGULATING POOL El DRYWELL [IPLUMBING AND SEWERS. Cw
I NERXEY CERTJFY THAT I AY PROPERLY REOIrT[R[D ANP/OR ALTER.REPAIR,SEWER QR
LICENSED AS REQUIRED EY LOS ANGLES COUNTY AN (TATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT 1 R LEGAL OWN OF, AN INTEND TO DIfCON N[CT P4UG AND
R[SID[ IN, THE AW RI BED Rz•I IAL ABANDON HOUR[;EWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMITTEE BEEP,PIT(.) [� C[SSPOQLS
ATION ROBERT A. WOOD
cK. M•I CksH SUPERVIOING MFICHANICAL ENGINEER
�'y.tea 7 •r..
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