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CEEOB IS ee APPLICATI FOR P RMI-
76A eAaG
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION Bu1LGINc 7 -t-
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JOHN A LAMBIE. COUNTY ENaINE[R ADO""•• J 7 _
COLEMAN W JENKINS SUPT OF BUILDING
LOCALITY
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OB APPLICANT TO FILL IN °"°•' 'T {
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NO DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
NOUS[SIM"CONNECTING TO Y CUR" P L ML TOPIL
PU•LIC SEWER O fE 00
SEPTICTANK PAG[FIT P C NO
PITS AND/OR GRAINFIELD 0 IT GO CO IMP NO JOp NO
HOUSE SEWER CONM[CTINO TO Y
PRIVATE DISPOSAL SYSTEM C ED 00 TRUNK PERMIT NO ROAD PERM IT NO d
CONNECTOTI.Hl DOO RECORD IX{TR N
WORKTO,OUSESEWER
0 53M U
OVERFLOW SEEPAGE P IT GRAINFIELD
E}TN CESSPOOL MYWELL MANHOLE O Ee M 0
ALTER REPAIR OR ApANpON NOUt[ HWY PROT WIDENING W
SEWER OR}O�ID{�PO�pA/L SYSTEM
0 $O OO STATE ENCROACHMENT d
PERMIT NO =
INDUSTRIAL
WAST[APPROVAL
OWNER'S CHARGED
OWNER'S PERMIT f 2 00
AUTHORIZATION TOTAL 00
CONNECTION CHARGE FE[
I HAVE AT THIS GAT[ A CONTRACT WITH THE HEREIN NAMED CON REIMDURD[M[NT F[[
TRACTOR TQ_COMN[CT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE "U SLIC W DAY OF � I APPROVAlS
DATE INMECTORSSIGNATURE
SIGNED THIS '/I /
OWNER OR NEW HOUR[SEWER
OWNERS AGENT_ CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
SEPTICTANK SEEP PITIS)
1 N["LY ACKNOWLEDGE THAT 1 NAVE ROAD THIS APPLICATION ANO/OR MAINFICLO
I1H0
pTATSE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLU MSIN0 ANP SEWERS CESSPOOL ❑ DRYW[LL ❑
I HERE"Y CERTIFY THAT I AM PROPERLY REGISTERED AMO/OR` ALTER REPAIR SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM d
CALIFORNIA OR T I AM THE LEGAL O R OF AND INTEND TO
RESIDE IN T E gIB[O R[61 TIAL PROKRTY DISCONNECT PLUG AND
ABANDON HOUSE SEWER
{16NATUR[
OF PERNTYT[ -low BACKFILL SEPTIC TAN"1 ❑
BEEP PITISI ❑ C[SSPOOLE
J6! CATION JACK R ALLEN
/ SUPERVISING MECHANICAL ENGINEER
LN M O CASH
LAro 7 2 5 OR OCT20 1 0 D 8.00- 4