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76 A6a2L APPLICATI FOR Pb MIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BU LOINS /"f7
I ADDRESS 7 L-60
LOCALITYrn/
NEAREST
FOR APPLICANT TO FILL IN CROGG BT.
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DEGCgIPTION LOT NO. /I +yy ��/I OWNER
l �Y C:z MAIL
BLOCK ``TRAyCT�j ( MAILADDRESB �[ �J
SIZE OF LOT ks- /A C,O NOW ON LOTS CITY rlP&t 1- 1/ TEL. NO. ?f
BUILDINGS [/V(yC fj�/�l/L y-jp 1..LI'v�] DISTgICT NQ GROUP MAP EGGED BY,
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CONTRACTOR S[�U Z -_/ 0�'
ADDRESS CONNECTION DATA {��'�
STATION DEPTH -
CITY TEL. NO.
STATE LIC MANHOLE REFERENCE UPPER
LICENSE NO. CLASS LOWER
NO, DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE:SEW ER GONNFCTINGSO– _.- - -- _ Y:- - ---= CURB - P.L - M:L.,TO PL�---
PUBLIC SEWER @ r
v.c.No. a
'SEPTIC [ANK.SEEPAGE PIT OR JOB NOI O
PITS ANO/OR GRAINFIELD � CO.IMP. NO. . -
V
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATECONNECT
DISPOSAL SYSTEM 0
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT Iv +sd[x RECORD. INGTR.NO. DATE O
OVERFLOW
HOUSE SEWERIT u
OVERFLOW GEOL. R PIT GRAINFIELD ` W
E%TN..GESSPOOL.DRTWELL MANHOLE
ALTER.,.H O .HOUSE HWY.OR ST.WIDENING 1 - N
SEWER SYSTEM STATE'ENC R OAC HMENT _ Z_
PERMIT NO. �-
INDUSTRIAL
WASTE APPROVAL
OWNERCHARGES
$ PERMIT S
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE
IHAVE AT THIS DATE s CONTRACT WITH THE HEREIN NAMED CON. REIMBURSEMENT FEE
TRACTOR TO CONNECT THE.ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF-19—
OWNER
F 19_OWNER OR NEW HOUSE SEWER
OWNERS AGENT -
CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
SEPTIC TANK.GRAINFEF.IELD PIT(E) -
HEREBY ACKNOWLEDGE E 15 RREC RENO THIS APPLICATION AND/OR pRAINFIELD
ANO STATE CTHATOUNTY
THE ABOVE IE CORRECT ANO AGREE E COMPLY
WITH ALL COUNTY ORp1NANC£5 AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ ORYWELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR pLTE..RlP9 .SEWER OR �J
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM 1,�J
CALIFORN I A OR THAT I AM THE LEGAL OWNER OF. ND INTEND TO DISCONNECT PLUG ANO
RESIDE IN, THE ABOV DESCRIBED HE., N IAL P O RTY.
ABANDON HOUSE SEWER
SIGNATURE
OF PERMRTEE BACKFILL SEPTIC TANKS ❑
SEEP.PIT IB) ❑ 1E55POOlG ❑
VALIDATION
CASX
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