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APPLICATION FOR PERMIT u
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION wILDINo
ADDRESS .J
LOCALITY
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OR APPLICANT TO FILL IN CROSS STLEGAL
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PTION LOT NO OW N[R
MAIL
BLOCKBRACT - ADDRESS
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NO[ �G-,4CW IL—le467 e, OIICII�T�gICTRO [ROUP NAIV OV � IlCTORS CONNECTION DATA
T4 NO RATION G/ 115- D[ITM LICvMANHOLE REFERENCE Z/ � QOUII[RE NOS CEA[[ ZDH R O F ORK ISE TYPE OF CONN[tt10N LING"FROM3SOUS[[EW CR CONNECTING TO Y CURE I L M L TOIL JSLIC SEWER 0 $700 PI IC LANK SECIAO[IIT OR IC NOITS AND/OR D.AIINFJELD a /1000CO IMPJOE NOOUSC S[W[R CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO
RIVATE DISPOSAL SYSTEMONNECT ADDITIONAL SLOO OR AFFIDAVIT [.IEEE W1RMR RECORD IMETI NO MY[
ORK TO HOUSE SEWER O SSW
OVERFLOW SKKPAGE PIT ORAINII[LO O
[KTN CESSPOOL DRYW[LL O [[OO NWY OR ST WIDENING Cl
ALTER PAIR OR ABANO NHOUSE LC
SEWER RD AL SYSTEM 0 !300 STATE ENCROACHMENT O
MANHOLE O $7 00 PERMIT NO t3
INDUSTRIAL C\.
E
�p� WASTE APPROVAL
O'.INE.E[S PERmT sCHARGES
AM101 SATION 'TOTAL I=
/ CONNECTION CHANGE FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT R[
TRACTOR TO LIC SE [CONNECT THE ABOVE DESCRIBED [RISTINO DWELLING p
TO THE PUBAMOVPJS DATE IMSP[CTO SIGNATURE
SIGNED THI6 DAV OF —1 WIZZ
OWNER OR NEW HOUSt SEWER
OW N[RS AGENT CONNECT ADOITIONAL
AODR[HS BUILDING OR WORK
SEPTIC
I HERESY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OTANK SEII IITIS)
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY AMO/OR MAIXFI[LD
WITH ALL COUNTY ORDINANCES AND STAT[ LAWS RCOULATINO
PLUMBING AND SEWERS CESSPOOL ❑ DRYWCLL ❑
I HERESY CERTVY THAT I AM FROP[RLY R[GISTCR[D AND/OR ALTER RKPAIR S[WCROR
LICENSED AS REOUIRED BY LOSLANGLES COUNTY AMD STAT[ OP SIWAO[DISPOSAL SYSTEM
CALIFORNIA OR THAT 1 AM THE EOAL OWNER OF AND INT[MO TO DISCONNECT PLUG AND
RESIDE IN THE ABOVE SCRIBED RESIDENTIAL ROP I ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PEIMTTTE[ I1 !}� KEEP Pais) ❑ CESSPOOLS
VALIDA'I N CR M O CASH
4 7 1�-NAY 24 1 0 0 1 5.0 O es6