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76A642D APPLICATION FOR PERMIT
11
COUNTY OF LCIS ANGEL S$ SEWER—SEWAGE DISPOSAL
DtPARTN02IT OF COUNTY ENGU=
BUELDING AND SAFETY DIVISION euILDInG37
w�JOHN IL �^ ADDRc■a r
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LOCALITY
NEAREST '
FOR APPLICANT TO FILL IN CR0O6 ST.
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DESCRIPTION LOT NO. W7 06
OWNER
MAIL
f
BLOCK TRACTADDRESS
NO. OF EL-DOM.SIZE OF LOT NOW ON LOT Cf'fY TEL NO.
US[ OF DISTRICT NO. MAP PRO-C[SS DY
BUILDINGS
- a
(�CONTRACTOR �
ADDRESS �c +( CONNECTI N DATA
CITY TEL. NO. ��T STATION _ �( DEPTH
MANHOLE REFERENCE UPPER
R[OI■T RATION NO. COUNTY
NO. DESCRLPTION OF WO K FEE TYPE OF CONNECTIO LENGTH OM
HOUSE SEWER CONNECTING TO Y, CUR .L M.L.TO .L
PUBLIC SEWER t S0.D0 P.C.NO.
SEPTIC TANK•S P O[ IT OR- CO.IMF.NO. �� Q lYJ
FIT/AND/OR DRAINFI ELD 8
10.00
OU/[/EWER CONNECTIIIGTO TRUNK PER b. ROAD PERMIT NO. DL
PRIVATE DISPOSAL SYSTEM $3.00
qOp4mKCT ADD TIONA ■ AFFIDAWT I SAm� EUMVIT RECORD.IN
�TOHOU/[S[WLR 51.00� p"(]
OVERFLOW/[[PAG[PIT,DRAINFIKI
U[TN.,CESSPOOLDRYWELLMANHOLE [0.00 d
ALY".R AIN O DO H HWY.OR FT.WID[I11NG h
SEWER OR DISPOSAL SYSTEH Q 1.00 STAT[ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
0WNER'3 PERMIT s s 00
Cq NN[CTION CHARD[F[[
A=ORMATION TOTAL FEE
.1 HAVE AT THIS DAT[ A CONTRACT WITH THE HEREIN NAMED CON- REIMCURSEM[NT FEE
TRACTOR TO CONNECT THE ABOVE D[SCRIS[D �7�T� LS
TO tHE PUBLIC ■ / / APPROVADATE I CT '■SIGNATURE
SIGNED THIS A`( O 7PL -7
OWNER OR i- NEW HOUSE SEW
OWNERS AGENT CONNECT ADDITIONAL
BUILDING OR WQRK
ADDRESS SEPTIC TANK.SEEP.PIT(8)
1 H[R[BY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION AND/OR DRAINFI[LD
AND STAT[ THAT THE ASOVE I■ CORRECT AND AOR[[ TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS
REGULATIIJG
FLU MB
ING AND ■[W ERS. CESSPOOL Cl DRYWELL ❑
OR ALTER,RIPA
I HEREBY CERTIFY THAT 1 AM PROPERE
LY REGISTRED AND/ R.SEWER OR
LICXNSED AS REQUIRED BY LO■ ANOLES COUNTY AND STATE OF ■[WAG[DI/FOCAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF,AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ASO KA IBES RESIDENTIAL RTY. ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEF'�IC TANKS Elr
OF PERMITTEE F .PIT(/) LJ CESSPOOLS G'
'DIA. ROBE T A. WOOD
SUPERVISING MECHANICAL ENGINEER
CK. Y.O. CASH
LGO 6 9 8�8 W23 1 0 0 1 0.00 V