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78AS4ewe4ED APPLICATION FOR PERMIT
COUIM OF LOS ANGELES SEWER SEWAGE DISPOSAL
DEPARTbMNT OF COUNTY ENGINFM
BUILDING AND SAFETY DIVISION JA
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ALITY G
RlifFOE APPLICANT T IN / SSST.LEGAL <
D[SCRIFfION LOT NO. J• NER
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NO. OF SLDOS.
SIZE OF LOT NOW ON LOT CITY / TIL. N0.
BUOF
BUILDINGS N
DISTRICT O O D UP MAP PROC U%6XBY
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COPlT RACTO tC4;K_ 7�p
ADDRESS `1C�/ CONNECTION DATA
CITY TSN N P DEPTH
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STATX MANHOLE R[Fllf[NCI QV�R
R[OISTRTION Np. COUNTY
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No- DESCRIPTION OF WORK ME P[of c N[ NGTH Pp6M
HOUSE SEWER CONNECTING TO Y M.L TO P
PUBLIC SEWER 0 $5.0.0 P.C.NO.
SKFTIC TANK.SC[PAG[Prr OR CO.IMP.NO. JOB NO.
PITO AND/OR DRAINFIELD $10.00
H OUB[S[W[R CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. 1� -2.
PRIVATE DISPOSAL SYSTEM $$.00
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT I EAMN [AEOIE[T RECORD.INSTR.NO. DAT[
WORK TO HOUSE SEWER =7.00
OVERFLOW■ENAOE PIT,DRAINFIELD
[XTN.,CISSPOOL-DRYWELL,MANHOLE 0 $5.00
ALTER.R PAIR OR ABANDON HOU HWY.OR ST.WIDENING
SEWER OR DISPOSAL SYSTEM /9.00 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPRo`[G4
_ OWNEE'3 PERMIT i 2 00
AUTHOMATION I TOTAL FEE FFM CONNECTI N CHARGE PE[
I HAVE AT THIS DATE A CONTIT
RACT WITH THE HEREIN MED CON- REIMeURSEMN
[ T FI[
TRACTOR TO CONNECT THE ABOVE DEACRIBID LEISTING DW[111NO APP$OV
TO THI EAL�PUBLIC ■ WER. AM DAT INSP[ OR'B M ONATURI
SIGNED THIS DAY OF to_ ��
OWNER OR ��AIA J NEW HOU°[S[WKR
OWN ERb AGENT ��/�.�G!
CONNECT ADDITIONAL ,
BUILDING OR WORK
ADDRUS
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION ANTIC RANK,e[IP,PIT(S)
AND STAT[ THAT TME AbOV[ IS CORRECT AND AOR[[ TO COMPLY AND/OR DRAINFI[LD
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLU Me ING AND SEWCESSPOOL ERS. ❑ DRYWALL ❑
IHERESY CERENR
TIFY THAT I AM PROPLY X019TKRED AND/OR ALTER,REPAIR.SEWER OR
L IC[NS[D AS REGUIR 'RASED S ANGLES UNTY A D STAT[ OF S[WAOe DISPOSAL SYSTEM
CALIFORNIA OR THAT [ LEGAL O R D INTI HD TO
RESIDE LN, THE AS D I P rE RTY. DISCONNECT PLUG AND
ABANDON HOUSE SEWER
SIGNATURE BACKFILL•KP[J_C TANKS ❑
OF PERMITTEE SEN.PIT(a) Lj C[SSPOO Le
VALIDATIONROBERT A. WOOD
CK. M.O. SUPERVISING MECHANICAL ENGINEER
CATH
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