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COUNTY OF LOS ANGELES SEWER—SEW DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDINGD
ADDRESS
LOCAL TTY
NEAREST
FOR APPLICAN�Ty TO FILL IN CRo■BLIEGAL
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D[ CRIPTION
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• NO. OF BLDGM.
SIZE OF LOT � o NOW ON LOT CITY TEL. NO.
USE OF DISTRIC R0. GROUP
MAP CEBBED BY
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CONTRACTOR V
ADDRESShe CONNECTION DATA
CITY Til.. N0. SSATION3 D.
CJ_AY
■TAT[ MANHOLE R[FIRENCI J O LR
LICENSE NO, T
No. Dfr6CRIPTI0N CW WORK FII TYr[OF CONNECTION LENGTH FROM
HOU■[■KWSR CONNECTING TO K CUR■ P.L MA-TO PA- O
PUBLIC B[W t,P. HO.
■ I ANK.• AO[FI OR CO.IMP.NO. JOS NO, a
FIT■AND/OR DRAINFI ELD 0 O
GUS[GIrWKR CONNECTING TOL"
TRUNK PERMIT NO. ROAD PICA IT N O Cr �/
PRIVATE DISPOSAL SYSTEM ! p�
CONNECT ADDITIONAL■ O.OR AFTIDAVIT •A11n WO[[R R[C ORD.INSTIL.NO. DATt O
WORX TO HOU4S SEWER 0
OVERFLOW SEEPAGE PIT.DRAININELD
EXTN..PEBSPOOL.DRYWELL uANHOL[41
A'LTER.REPAIR ASA N OU• HWY.OR ST.WIDENING O.
■[W[R OR DISPOSALSYSTIE STATE QICROACH14KMT �
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PERMIT NO.
INDUSTRIAL
WAST[APPROVAL
ov els PERMr s O 0 CHARbp
A=OB=ON I TOTAL F£E Oa CONNECTION CHARD[TEE
I HAVE AT TNI■ DAT[ A CONTRACT WITH TH[ HXRXiA NAMED CON- R[IMBURSEM[NT FII
TRACTOR TO COMP49CT THE ASOV[ DESCRIBE EXISTING DW[LLINO PPR �y�
TO THE PUBLIC SEWER. APPHOVAT� DATE INSPECTOR'S SIGNATURE
SIGNED TM16 ziG_
OWN[IL OR NEW NOUS[SEW[R
OWNERS AGENT FA CONNECT ADDITIONAL
BUILDING OIR WORK
ADDRESS SEPTIC TANK.■EER.PITH
I HEREBY KNOWLEDGE THAT I HAVE READ TNI■ A CATION AND/OR DRAINFIELD
AND STATE THAT TH[ ABOVE 1■ CORRECT AND AGRII TO COMPLY
WITH ALL COUNTY 0RDINANC[S AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CIISPOOL ❑ DRYWILL ❑
I HEREBY CERTIFY THAT �AM PROPERLY REGISTERED AHD/OR ALTER,REPAIR.BEw[R OR
LICENSED AS R[OUIR * ANGLES COUNTY AND STAT/ OF SEWAGE DIBPOSAL SYSTEM
CALIFORNIA OR TH 4[GA,L OW11[ROF. AND INTEND TO DISCONNECT PLUG AND
RESIDE IN. THE A B[D REBIDENTIAL PROPERTY. ABANDON HOUSE■EWER
SIGNATURE SACK FI LL
Ot P[RMTTT[E CESSPOOLS CIO-24
ATION
CK.
M.0. CASH