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`EeDB(REV °"A'ks APPLICATION FOR PERMIT
SEWER - SEWAGE DISPOSAL
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN FOR
NO. GROUP MAP PROCESSED BY
BK PG
BUILDING -•
ADDRESS
CONNECTION DATA
LOCALITY <•
NEAREST DEPTH
CROSS ST. i"
UPPER
E REFERENCE LOWER
OWNER - PE OF CONNECTION LENGTH FROM
MAIL CURB P.L. M.L.TO P.L.
ADDRESS
P.C.NO.
NO. JOB NO.
CITY TEL.NO.
LEGAL ERMIT NO. ROAD PERMIT NO.
DESCRIPTION LOT NO.
Z"
IT WAIVER EASEMENT RECORD.INSTR.NO. DATE
BLOCK TRACT ��ei� «-
NO.OF BLDGS.
SIZE OF LOT NOW ON LOT HWY. ST.WIDENING
USE OF
BUILDINGS CROACHMENT
PERMIT NO.
CONTRACTOR INDUSTRIAL
WASTE APPROVAL
ADDRESS CHARGES
CITY TEL.NO. CONNECTION CHARGE FEE AAQ
STATE LIC. ^' REIMBURSEMENT FEE u
LICENSE NO. CLASS :?�
NO. DESCRIPTION OF WORK FEE APPROVALS W
DATE INSPECTOR'S SIG NATO J
HOUSE SEWER CONNECTING TO -
PUBLIC SEWER
NEW HOUSE SEWER
SEPTIC TANK,SEEPAGE PIT OR (,[
PITS AND/OR DRAINFIELD CONNECT ADDITIONAL Q
HOUSE SEWER CONNECTING TO BUILDING OR WORK �7
PRIVATE DISPOSAL SYSTEM
SEPTIC TANK.SEEP,PITIS)
CONNECT ADDITIONAL BLDG.OR
WORK TO HOUSE SEWER AND/OR DRAINFIELD a
OVERFLOW SEEPAGE PIT,DRAINFIELD CESSPOOL [IDRYWELL❑ W
EXTN..CESSPOOL.DRYWELL.MANHOLE
ALTER.REPAIR OR ABANDON HOUSE ALTER,REPAIR.SEWER OR
SEWER OR DISPOSAL SYSTEM SEWAGE DISPOSAL SYSTEM
DISCONNECT PLUG AND
ABANDON HOUSE SEWER
BACKFILL SEPTIC TANKS ❑
SEEP.PIT(S)❑ CESSPOOLS
OWNER'S Permit
AUTHORIZATION TOTAL FEE VALIDATION
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER.
SIGNEDTHIS DAY OF 19
OWNER OR
OWNERS AGENT
ADDRESS
IHEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY 1
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS.
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OFg ••p ' -
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF,AND INTEND TO RE-
SIDE IN,THE ABOVE DESCRIBED RESIDENTIAL PROPERTY.
SIGNATURE
OF PERMITTEE