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76A842D 60 APPLICATION FOR PERMIT IJ
COUNTY OF LOS ANGELES SEWER--SEWAGE DISPOSAL,
DEPARTMENT OF COUNTY ENGINEER
BUILDING
BUILDING AND SAFETY DIVISION ADDRESS, ,
A- IE
M A"
ENS&Fouuty Engineer
VAOLYA Sup't of Building LOCALITY
A
NEREST jL,
FOR APPLICANT TO FILL IN CROSS ST. Z.-
LEGAL
DESCRIPTION_-LOT NO. OWNER
BLOCK TRACTMAIL
ADDRESS
NO.OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF
DISTRICT NO. GROUP MAP PROCESSED BY
BUILDINGS BK PG
CONTRACTOR
e -J
ADDRESS CONNECTION DATA
STATIONDEPTH
CITY EL.NO�
la '
STATE MANHOLE REFERENCE
-/
REGISTRATION NO, c COUNTY
NO. 1 DESCRIPTION OF WORK FEE
HOUSE SC VER CONNECTING To
I LU51:IC SEWER_ TYPE OF (fNVECTION' LENGTH FROM
I E
SEPTIC TANK. SEEPAGE PIT OR Y. /CURB 1 P.L. M.L.TO F.L.
PITS AND/OR DRAINFIELD @ 404
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN.,, @ &0
-ESSPOOL.DRYWELL 7-77, , P.C.NO.
DI
HOUSE SEWER CONNECTING TO j
PRIVATE SPOSAL SYSTEM @ JO. CO.IMP, NO. JOB NO.
CONNECT ADDITIONAL BLDG.OR --y
0
WORK TO HOUSE SEWER TRUNK PERMIT NO. ROAD PERMIT No.
ALTER, REPAIR OR ABANDON HOUSE
SEWER OR DlS1$1.40 STATE ENCROACHMENT ca
- WIT-WIT NO, 0
INDUSTRIAL
WASTE APPROVAL
CHARGES Fn
OWNER'S PERMIT 2 00 CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE IZ ,41,- REIMBURSEMENT FEE
I HAVE AT THIS DTE A CONTRACT THE HEREIMED
TRACTOR TO CONNECT THE ABOVE DESCWITHRIBED EXISTIN NGGDWELLICON-
NG APPROVALS DATE INSPECTOR'S SIGNATURE
TO 'THE PUBLIC SEWER.,
SIGNED THIS DAY 0, 9 ' NEW HOUSE SEWER
OWNER OR .fi- CONNECT ADDITIONAL
OWNERS AGENT
BUILDING OR WORK
ADDRESS..__ l- :j SEPTIC TANK,SEE?.PITS)
AND/1R DRAINFIELD
I HEREBY ACKNOWLEDGE THAT IAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE Is CO RECT AND AGREE TO COMPLY CESSPOOL [I DRYWELL
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING —ALTER, AIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR
LICE.NED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND
ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM THE LEGA; OWNER OF THE ABOVE
DESCRIBED RES I DE 11,T),10L,PROPERTY, BACKFILL.SEPTIC T=I)CL,
SIGN SEEP.PITS) C
.SIGNATURE
OF PERMITTEE-4L�J!��
VALIDATION ROBERT A. WOOD
CIL U.0. CASH SUPERVISING MECHANICAL ENGINEER