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C APPLICATION FOR PERMIT 1
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COUNTY OF LOS ANGELES SEWER SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENG2MM
BUMDING AND SAFETY D�MISION ADUILDING DRESS 02 V d
C IASOSAA AD GHQar
IN Sup County go!Bu 1ding
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FOR APPLICANT TO FILL IN CROSS T �:�/✓��r l�
LEGAL �
DESCRIPTION LOT NO � b �/ OWNER 7 C
r
BLOCK TRACT MAIL
NO OF BLDGS
SIZE OF LOTQ NOW ON LOT CITY EL NO
USE OF
BUILDINGS DISTRICT NO GROUP MAP
LPG
HK
CONTRACTOR V
ADDRESS CONNECTION DATA /~
CITY TEL �0 l-3 f^ STATION DEPTH
STATE MANHOLE REFERENCE UPPER
REGIS RATION NO / COUNTY LOWER
NO DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO 4-740
PUBLIC SEWER Q $S'Sw
SEPTIC TANK SEEPAGE PIT OR TYPE OF NNECTION LENGTH FROM
PITS AND/OR DRAINFIELD $) $S 00 Y CURB P L M L TO P L
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL MANHOLE @ $2 00
HOUSE SEWER CONNECTING TO P C NO
PRIVATE DISPOSAL SYSTEM @ $1 00 CO IMP NO JOB NO
CONNECT ADDITIONAL BLDG OR
WORK TO HOUSE SEWER Q $1 00 TRUNK PERMIT NO ROAD PERMIT NO
ALTER REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM 0 $1 0011
0 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PFIB $ 00 CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE REIMBURSEMENT FEE
T ACTOR TO CIS DATE A CONTRACT ONNECT THE ABOVE ESCR BED EXWITH THE ISTING DWELLI NAMED COX G APPROVALS DATE INSPECTOR S SIGNATURE
TO THE PUBLIC SEWER
SIGNED THI DAY OF 9_ NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL �a ! P
OWNERS AGENT --� BUILDING OR WORK t� .Z /�
ADDRESS SEPTIC TANK SEEP PIT(S)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL❑ DRYWELL❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS ALTER REPAIR SEWER OR 1 HEREBY CERTIFY THAT 1 AN PROPERLY REGISTERED AND/OR SEWAGE DISPOSAL SYSTEM
DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER _
CALIFORNIA OR THAT 1 AN THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIAL PROPER Y BACKFILL SEPTIC TANKS❑
SIGNATURE SEEP PIT(S) ❑CESSPOOLS ❑
OF PERMITTE 1
®r VALIDATIO ROBERT A WOOD
CK M 0 cASx SUPERVISING MECHANICAL ENGINEER
f_f66 8 4% FEB 18 r 3 A 300 �'