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$ COUNTY REGISTRATION NO � � ❑ COUNTY .
NO DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM r
HOUSE SEWER CONNECTING TO Y CURB P L Y L TO P L '
PUBLIC SEWER I @ f 3 50 L
SEPTIC TANK SEEPAGE PIT OR '
PITS'AND/OR DRAINFIELD Q f 3 00 -
OVERFLOW SEEPAGE PIT DRAINFIELDP C NO
E%TN CESSPOOL DRYWELL MANHOLE Q f 2 OD CO IMP NO 100 NO
HOUSE SEWER CONNECTING TO '
PRIVATE DISPOSAL SYSTEM Q f 100 TRUNK PERMIT NO ROAD PERMIT NO
CON N ECT ADDITIONAL BLDG OR STATE ENCROACHMENT
WORK TO HOUSE SEWER Q f 100 PERMIT NO '
ALTER REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM Q E 100 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
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AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
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I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON APPROVALS DATE INSPECOR SSIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER NEW HOUSE SEWER ji•L
SIGNED THIS DAYOF / 19_ CONNECT ADDITIONAL
OOWNER OR IWNERS AG ENir .�yd_ BUILDING OR WORK
SEPTIC TANK SEEP PIT(S)
ADDRESSIf AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION- CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE-IS CORRECT AND AGREE TO COMPLY-
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR SEWER OR '
.PLUMBING AND SEWERS _ �r` SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT 1, M PROPERLY REGISTERED AND/OR AND
DISCONNECT PLUG
LICENSED AS REOUIRED-BY S"ANGELES COUNTY AND STATE OF ABANDON HO PLUGUSE D
CALIFORNIA OR THAT. I-A aTHE-LEGA WNER, OF THE (ABOVE
DESCRIBED RESIDENTIAL P PERTY F ,I BACKFILL
SEPTIC
BEEP (BCESSPOO
SIGNATURE CESSPOOLS
`
OF PERMITTEE -
JOHN A`LAMBIE CO 4Y" NGIN EER ` r ALIDATION ROBERT A WOOD CHIEF PLSG INSPECTOR
CF Y 0' GSH
7187 DEC 410 A 500 p