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76AS420 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER SEWER-SEWAGE DISPOSAL
BUILDING AND SAFETY DIVISION
ADDRESS
JOHN A, LAMBIE, County Engineer
WILLIAM A. JENSEN, Supt of Building
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FOR APPLICANT TO FILL IN -------
LEGAL
DESCRIPTION LOT NO.
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PRIVATE DISPOSAL SYSTEM $.3-0G TRUNK PERMIT NO. ROAD PERMIT NO.
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SEWER O�R DISPOSAL SYSTEM @ $5.00 STATE ENCR,DA,-CHMENT —------
PERMIT NO.
IP D U STR I AL.
WASTE APPROVAL
CHARGES
OVVNER'S PERMIT
CONNECTION CHARGE FEEL
AUTHORIZATION I-MOTALF—EE-
HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- RE-;MBU-R-SEMFNFEE
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0 THE L C', SEWER. APPROV
T Pit B ALS 1 DATE ,NSP ECTCR'S StG NATO RE
SIGNED THIS___DAY OF______19_
NEW HOUSE SC
OWNER OR
NIT IINNICT ADDITIOIAI
OWNERS AGE:
UILDING OR WORK
HFRvBY ACKNO LEDGE THAT I HAVE READ THIS APPL(CATION
------ SEPTIC TANK,SFr..P,FIT(S)
I A AND/OR ORAINFIELD
AND $� TE THAT THE ABOVE IS CO RECT AND AGREE TO COMPLY
WITH ALL. COUNTY ORDINANfC.EAL
AND SYTE AWS REGULATING
FLU MB ING AND SEWERS. CESSPOOL _1 DRYWfELI. 7i,
HEREal.' CERTIFY THAT IAM
PROPERLY REGISTERED AND/OR AL---rH,REPAIR.SEWER OR
LICENS 0 AS RFOUIRE0 BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
C
ALIFORNIA 0 RTHAT I AM THE LEGAL. OWNER OF, AND INTEND TO CT DISCONNE
RESIDE IN THE ABOVE_DESCR!BED RES;DEN IAL PROPERTY_
Y.
,, , ABANDON ROUSE
tPLAUG AND
S E SEWER
OF PERMITTEE z BACKFILLSEPTic::TANK5 F-1
SEEP.Frr(s) 0 CESSPOOLS Lj'!
VALIDATION ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
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