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78L042D COUMOF pLOSPPELECpTION FORPERMIT
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DEPARTMENT OP CO;BLDGS
BUUMING AND SAFBUILDING
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LEGAL DESCRIPTION LOT NO OWN.BLOC[ TMCT MAILADDRESNO SIZE OF lAT NOW CITY YUSEDISTRICT NO GROUP YAP PROCESSED BT
BUILDINGS ) B[ ►0
CONTRACTOR !ADORE O ON DATAL NSTATION DEPTH
STATE MANHOLE REFERENCE
REGISTRATION NO /L5�3COUNTY LOWER
NO I
NI1 DESCRIPTION OF R FEE
PUBLICSSE EERCONNECTING TO f5 00
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PITS AND OR DRAINFIELD 00
OVERFLOW SEEPAGE PIT DRAINFIELD
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C NO
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ATR REPAIR DISP(OR AGARINL SYSTEM HOUSEE ENCROACHMENT
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E APPROVAL
CHARGES
OWNHH's PERNBT ECTION CHARGE FEE
AUTHORIZATION TOTAL PEE EURSEYENT FEE
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TRACTOR TO CIONNECT THE ABOVE DESCRIBED EXISTTINGI HAVE AT DATE A CONTRACT WITH THE HEREINAMED D ELL/NG APPHOVAIS DATE INSPECTOR l SIGNATURE
TO THE PUBLIC SEWER
SIGNED THIS DAY OF TB_ NEW HOUSE SEWER
OW NER OR CONNECT ADDITIONAL
OWNERS AG ERT BUILDING OR WORK
ADDRESS SEPTIC TANK SEEP PIT(S)
AND/OR DRAINFIELD
i HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE I8 CORRECT AND AGREE TO COYPU CESSPOOL DRYWELL
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR 9EW ER OH
PLUMBING AND SEWERS SEWAGE REPAIR
DISPOAL ER ORI
1 HEREBY CERTIFY THAT I A■ PR PERU REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED LOS AN LES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT TH GAL OWNER THE ABOVE
DESCRIBED REST ENTI OPE BACKFILL SE IC TANKS
SIGNATURE LEEP PITS CE33 LS
OF PERMI7TE
mT ALIDATION ROBERT A WOOD
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"A'•1° APPLICATION OR PERMIT �,�°
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DEPARTMENT OF COMM ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
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LEGAL
DESCRIPTION LOT NO OWNER
BLOCK TRACT MAIL
ADDRESS
NO OF BLDG!
SIZE OF LOT NOW ON LOT 401, CITT TEL NO
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BUILN S
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C TEL NO 9-0,3/71 TION
STATE MANHOLE REFERENCE
REGI STRATTON NO V COUNTY LOWER
NO I
�1DEESCRIPTI F WOR FEE
PUBLIC SEWEERCOMNECTING TO ® S 00
EW TYPE OF X ECTION LENGTH FROM
SEPTIC TK SEEPAGE PIT OR T CURB p p
PITS ANOIOR DRAINFIELD S 00
OVERFLOW SAGE PIT DR
N L EEPDRYWDRAINFIELD E 32 00
HOUSE SEWER CONNECTING TO F R NO
RI 1 POIAL lY EN 1 CO IMP NO JOS NO
CONNECT ADDITIONAL,BLDG OR TRUNK PERMIT NO ROAD PERMIT NO O
WORK TO HOUSE SEWER U
A T REP R ABANDON HOUSE I STATE ENCROACHMENT +y
qA op FERYIT NO
INDUSTRIAL
NA EAPPROVA
CHARGES
OWNEWS PERMIT s CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE I wier kii REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR l SIGNATURE
TO THE PUBLIC SEWER
SIGNED THIS DAY OF +9— NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADDRESS SEPTIC TANK SEEP PITS)
AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE 19 CORRECT AND AGREE TO COMPLY CESSPOOL Q DRYWELL
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWER! ALTER REPAIR SEWEROR
1 HEREBY CERTIFY THAT I AN PROPERLT REGISTERED AND/OR SEWAGE DISPOSAL SYSTEM
LICENSED AS REQUIRED A LOS A LES COUNTY A ATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT TX GAL OWNER 0 E ABOVE ABANDON HOUSE SEWER
DESCRIBED REST NTI ROPE BAC ILL SE5C TANKS
SIGNATURE SE PIT ! CESSP OLS
OF PERMITTE
mF toe 1--XALrI ROBERT A WOOD
a a
� M ° G>2 MUPERVISINO MECHANICAL ENGINEER
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