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APPLICATION FOR PERI
TLA tAiD COUNTY OF LOB ANGELES SEWE R-SEWAG POSALY
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING 11 �A
JOHN A LAMBIE, COUNTY ENGINEER ADDRESS
COLEMAN W JENKINS SUPT OF BUILDING p ��
LOCALITY
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ADDR{ES Z� CONNECTION DATA
RATION Z�Q S DEPTH
•TAT[ LIC MANHOLE REFERENCE UPPER
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NO DESCRIPTION OF WORN I[{ TYPE OF CONNECTION L[MOTM FROM
MOUSE$MEN CONNECTING TO CURB PL ML TO IL
PUBLIC E[W[R O SSW 00
L PTIC TANK PAG[PIT II I C NO
PITS AND/OR GRAINFIELD � tlO Op
CO IMP NO 'JR JOB NO
MOUS[SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO/g SZ O V d
PRIVATE DIBPOSALEYLTEM O 53W
V O
CONNECT ADDITIONAL• DO ON AFFIDAVIT RMTEE WTBTNT RECORD IMSTR NO DAT{ G1
WORKTO NOYB[EWER O tB 00
OVERFLOW 599PACK PIT GRAINFIELD O
t KTM CESSPOOLORYW{LLMANNOL[O 95 OO
ALTER REPAIR OR ABANDONHouse
XWY OR LT WIDENING W
SEWER OR GBPOSAL SYSTEM O 5300 STATE ENCROACHMENT D'
PERMIT NO Z
INDUSTRIAL
WAST[APPROVAL
OWNER'S PEBMR S t 00 CHARGES
AUTHOBPLATION I TOTAL FEE 7 CONNECTION CHARGE R[
1 HAVE AT THIS DAT[ A CONTRACT WITH THE HEREIN NAMED CON REIYSURS{M[NT I{[
TRACTOR TQCOMMCR TXE ABOVE D[BCRIBCD APPROVALS
TO TN[ PUBLIC SME* � D DAT[ 1 TOR 5 SIONATUR[
SIGNED THIS DAY OF /
OWM[q OI1 NEW MOUSE B[W{R
OWN[gB AG{MTS CONNECTADOITIOMAL
ADDRUE BUILDING OR WORK
ECPTIC TANK SEEP PITISI
I MEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/ON
DRAINFI{LG
AND •TATE THAT TX{ ABOVE 15 CORRECT AND AGRL[ TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLY MBIMG AND SEW'" ClBE.OL ❑ ORYWLLL ❑
1 HEREBY C[MRY TNA I •M PROPERLY RtOIR [D AMD/OR ALTER N{PAIR *EWER OR
LICENSED AS N{OYIR[D LOS ANGLES COUNTY D STAT, OF 'MAO[DISPOSAL SYSTEM
LIFORNIA OR THAT I TX6 LEGAL OWNER OI D INTEND TO DISCONNECT PLUG AND
RESIDE IN TXE AS D[SCRIB[D R[SI TIA KITTY ABANDON MOUSE SEW{R
SIGNATURE
OF IER BACKFILL L{P{jC TAMKt
SKIP PITISI U CWPOOLt
VAMATIW JACK R ALLEN
C 111 GASM ` SUPERVISING MECHANICAL ENGINEER
I Or,4 0 3 aR fAR11 1 0 D 7.00-