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78AB°A°42o APPLICATION FOR PERMIT
COUNTY OF LOS ANGMIM SEWER—SEWAGE DISPOSAL
DEPARTIUM OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
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DUCRIPTION LOT NO. S' OWNERA! 13,90 Al
MAIC
/LOCK TRACT ADDR W
NO. OF SLOGS.
■IZE OF LOT HOW ON LOT CrTy T=L NO.
U/L OF DISTRICT NO, OUP MAP PROCESSED W
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W ILDINGS
CONTRACTOR (/ f
ADDRW O ATA
CITY L, NO, RATION DEPTH
ATE MANHOLE REFEJIENCE
REGISTRATION NO. 2- f COUNTY
NO. D"CRIPTION OF WORK FEE TYPE of CONNECT[ GTH
U/E SEWER CONNECTING TO Y. CU P,L M.L.TO F.L.■LI ■EWER 1•00 P.C.NO_AWTI .
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FITS AH D/ORDRAINFI[LD [10.00 CO.IMF.NO,
_pzulrTlG O TRUNK FERMIT NO. ROAD PERMIT NO. V
PRIVATE DI/POSAL SYSTEM 11.00
CONNECTIGAYIT Sm"m I Lusa T RgrCORD,INSTR,NO, DATE OL
WORK TO HOUSE/EWER 17,00 O
OVKRItL6W/ AG P N I LD
LETN„CESSPOOL,DRYWELL,MANHOLE ■.00
HWY.OR ST,WIDENINO
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STA]'E ENCROACHMENT
PERMIT NO, _
INDUSTRIAL
WAST[APPROVAL
CHARGES
oo CONNECTION CHARD[FEE C> V e'
AUTHORIZATION I TOM FEE
'1 HAVE AT THISDAT[ A CONTRACT WITH THE HEREIN AMID CON- REIMBURSEMENT FEE
TXACTOTO THERTO PU■LICC SEW THE ABOVE DESC111SSD APPROVALS
DAT[ INSP[CTO R'B SIGNATURE
SIGNED THIS DAY OF 19
OWNpt OR NEW HOUSE OMER
OWNERS AGENT CONNECT ADDITIONAL
W ILDINO OR WORK
ADORES
1 HERESY ACKNOW L[DO[ THAT I HAV[ THIS APPLI ON
SEPTIC
D#AINFI[LDD/fO TANK.SEEP,FIT(S)
AND STAT[ THAT THE ABOVE IS CORRECT AND AGR[[ TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRY-WELL ❑
I HERESY CERTIFY THAT I AM PROPERLY REOISTERED AND/OR ALTER,RLPAIR,SEWIR OR
LICENSED AS REQUIRE LOS ANGLU COUNTY AND STAT[ OF SEWAGE DISPOSAL SYSTEM
LLIFORNIA OR AM THE LEGAL OWNER OF IHTE HD TO DISCONM[CT PLUG AND
UI D[ IN, TH[ ASANDON HOUSE/EWER
0F , M ■AC KFILL/[P'[1C TANKS ❑
OF P[RMI S[[P,PIT(S) Lf POO LJ
I
ATION Ro Ek WOO
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UP[fiVISING MECHANICAL ENGINEER
LICO 1 9 6 2t9 MAY 24 1 0 D 7.0 0`4
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