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7OA54 D 1 63 APPLICATION FOR PERMIT
CE 08
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION euILDING A
)DEIN A LAMM Couely EDpq[e..T AODREss
WILLIAM A TENSEN SMP I o! BMddmq
LOCALITY
NEAREST
FOR APPLICANT TO FII L IN , ENDS. BE
LEGAL
GES
CHIPTION LOT NO OWNER
MAIL
BLOCK TRACT / 7 ADDRESS
NO OF SLDOS
S12E OF LOT NOW ON LOT CITY TEL NO
VSEOF
DISTRICT NO GROVP MAP P ESSED OY
BUILDINGS
G _
CONTRACTOR C PJ`/
ADDRESSt / y C ECTIO I DATA
STATION / DEPTH
[
/y ATE MANHO LE REFERENCE ,J }
REGISTRATION NO G.� / Z� COUNTY
NO DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TOGO RB L ML TOPL GI
PUBLIC SEWER ® 33 00 J
NO pT,
SEPTIC TANK SEEPAGE PIT DR CO IMP NO CY JOB NO O
PITS ESEWE CONNECTING
® S1000
HOUSE DISPOSAL
CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO
PRIVATE CONNECT ISPOSALAL L. i300
CONNECT HOUSE SEW BLDG OR AFFIDAVIT A1• A¢[n[ RECORD INeTR NO PATE y
/
WORK TO SEEP GEPIT i3 DO UC7 Z
OVERFLOW SEEPAGE PIT GRAINFIELD
EXTN CESSPOOL ORYWELLMANHOLE® f300
ALTER REPAIR OR ABANDON HOVeE HWY pR BT WIDENING
SEWER OR DISPOSAL SYSTEM 8 i3 GO STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
��T�T� WASTE APPROVAL
0�.1�LRS PERMTLS 2 00 CHARGES
AUTHORIZATION TOTAL FEE O �d CONNECTION CHARGE FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE OE CR DED CX TIN ELLING APPROVALS _
TO THE PU eLIC 9EWE DATE INSPECTOR D SIGNATURE
SIGNESIGNED THIS__.DAY O F 19
OWNER OR NEW HOUSE SEWER
D
AGENT CONNECT ApOITIONAL
ADDRESS ® BUILDING D WORK
SEPTIC TANK SEEP PIT(B)
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION ANB/OR DRAINFIELD
AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ ORYWELL ❑
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AN ALTER REPAIR SEWER OR
LICENSED AB PEOUIRE lBT LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAI M THE EGAL OWNER OP ND INTEND TO DISCONNECT PLUG AND
RESIDE IN THE ABO pESC D RESIDENTIAL OPERTY ABANDON HOUSE SEWER
SIGNATURE ❑
OF PERMITTEE BACKFILL SEPTIC TANKS
SEEP PITS) ❑ CESSPOOLS
VALIDATION ROBERT A WOOD
CK M o EA SUPERVISING MECHANICAL ENGINEER
Le�06562b JUL l ! o b 1 0.00- /