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D APPLICATION FOR PERMIT: ;io, :,D.. ,I 1
COUNTY OF LOS ANGELES1•
SEWER-SEWAGE ,DISPOSAL , ,
DEPARTMENT OF COUNTY ENGINEER — -
BUILDING AND SAFETY DIVISION ADDRHSSG t
]]OHF A LAMBIE Cooa "
ty En�isee[ T
` WHJ.IAM A JMSEN Sop t o1 Buddmp LOCALIT fl lG - 1v '
NEAREST i • y r
FOR APPLICANT TO FILL IN c.Dss sT ry
LEGAL
DESCRIPTION LOT NO OWNER' t G
BLOCK - TRACT MAIL
ADDRESS Y'
NO OF BDGS -
SIZE OF LOT NOW ON LOT CITY EL NO 7o
BUUSE
OF
DINGS DISTRICT H I
K PG AP •PROCESSED BT ;
CONTRACTOR 3
ADDRESS CONNECTION DATA
CITYL NO STATION DEPTH v
STATE MANHOLE REFERENCE UPPER
REGISTRATION NOCOUNTY LOWER '
No DES IPTION OF WORK FEE -
HOUSERSEWERCONNECTING TOPUBLIC S 00
TYPE OF ON CTION LENGTH FROM
SEPTIC TANK SEEPAGE PIT OR ,Y CU M L TO P L
PI TS AND OR DRAINFIELD 's 00
OVERFLOW SEEPAGE PIT DRAINFIELD li
EXT. CE SPOOL DRYWELL S 00
PR VATEHOUSESEDISPp AL SYSTIEM TO S 00 'CO IMP NO JOB 00 1
M
CONNECT ADDITIONAL BLDG OR -� p0
WORK TO HOUSE SEWER s 0 .TRUNK PER ROAD PERtl
V
SLWER REPAIR IR OR ABANDON HOUSE @ S 00 STATE ENCROACHMENT O
PERMIT NO
INDUSTRIAL - -
WASTE APPR VAL
a
CHARGES ILi
OWIIIF.R•S PERMIT E 2 00 CONNECTION CHARGE FEE fi
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEEI HAVE AT T
TRACTOR TO CIS DATE A CONTRACT ONNECT THE ABOVE DETH THE HEREIN SCRIBED BED E LISTING AMED CON-DWELLIING APPROVALS DATE INSPECTOR SSIGXATURE
TO THE PUBLIC SEWER `
SIGNED THIS - DAY OF - +9_ NEW HOOSE SEWER -
OWNER ORAG CONNECT ADDITIONAL �W 17 dl� �✓1 �:•SY
OWNERS AGENT CONNECT
WORK PW G � -
ADDRESS SEPTIC TANK SEEP PIT(S)
AND/OR DRAINFIELD
I HEREBY-ACKNOWLEDGE THAT 1 HAVE-READ THIS APPLICATION- - - - - �--• _
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL [I �• ' ISI .-f
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWER OR _
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND,STATE.OF- ABANDON HOUSE SEWER
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIA PROPERTYBACKFILLSEPTIC TANKS 0
'SIGNATURE SEEP PIT 9 0 CESSPOOLS 0
OF PERMITTE (/
®' VALIDATION ROBERT A WOOD ,
CC ,M o WB _ SUPERVISING MECHANICAL,ENOINEER
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