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76A 642D-CE808-10 71 APPLICATIOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISIONBUILDING
ADDRESS
LOCALITYNEA `E V
FOR APPLICANT TO FILL IN CROSSSST % S
LEGAL
DESCRIPTION LOT NO Q � OWNER (�
MAIL
BLOCK TRACT ADDRESS I
NO OF BLDGS -
SIZE OF LO NOW ON LOT fIR
TEL NO
USE OF
BUILDINGS GROUP MAP CESSED BY
BK p
CONTRACTOR ` C a..7!/V
ADDRESS 6 �ow F" ••• CONNECTION DATA
CITY TEL NO I i� DEPTH
STATE LIC yV C/ UPPER
LICENSE NO 6 !-� GLASSERENCE CNO DESCRIPTION OF WORK FEE CONNECTION LENGTH FRROM
HOUSE SEWER CONNECTING TO CURB P 1 M L TOP LUBLIC SEWER ! $7 00SEPTIC TANK SEEPAGE PIT OR J C NO
PITS AND/ORDRAINFIELD S1000 JOB NO
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO 4
PRIVATE DISPOSAL SYSTEM 88 00 O
CONNECT ADDITIONAL BLDG OR AFFIDAVIT wAIY[■ cllsew�NT RECORD INSTR NO DATE 0
WORK TO HOUSE SEWER 0 $300
OVERFLOW SEEPAGE PIT DRAINFIELD IX
EXTN CESSPOOL DRYWELL SS 00 HWY OR ST WIDENING
ALTER REPAIR OR ABANDON HOUSE I.—
SEWER
ISSEWER OR DISPOSALS STEM $300 STATE ENCROACHMENT W
MANHOLE $7 00 PERMIT NO DV
INDUSTRIAL H
���}�pNER WASTE APPROVAL Z
OWNER S PERmrr f 9 00 CHARGES
AUTHORIZATION TOTAL FEE d 020 CONNECTION CHARGE FEE
1 HAVE AT THIS DATE A 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 OR NEW HOUSE SEWER
OWNERS AGENT
CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
SEPTIC TANK SEEP PIT(S)
4HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION AND/OR DRAINFIELD
ASTATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
1HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF AND INTEND TO DISCONNECT PLUG AND
RESIDE IN THE ROVE DESCRIBEDESID NT L PROPERTY ABANDON HOUSE SEWER
SIGNATURE / BACKFILL BE S ❑
OF PERMITTEE SEEP PIT(S) CES POOLS ❑
VALIDATION cK M 0 CASH
6 99L'_'FE8 510 0 1 000
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