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SEWER—SEWAGE DISPOSA
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION
FOR APPLICANT TO FILL IN DISTRICTNO GROUP tX MAP PS CESSED BY
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CONNECTION DATA
NEAREST STATION 09-H
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MANHOLE REFERENCE 3
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OW NCR TYPE OF CONNECTION NOTX PRO
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DESCRIPTION LCT NO
AFFIDAVIT RIIt.. OEER[rt RECORD INOTR MO DR[
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NO OF [Looe
SIZE OF LOT ryOW ON LOT HWY OR{T WIDENING
USE OF STAT[ENCROACHMENT
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STATE LIC A REIMBURSEMENT F[[ O
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No DESC I"IO OF W RK F[[ APPROVA7S DATE INSP[CTO/fS SIGNATURE (U
HOUSE SEWER CONNECTING TO I a
PUBLIC SEWER O /
mfPTjc TANK SEEPAGE FIT ORNLW NOUS[S[W[R
PITS AND/OR DRAINFI[LD O CONNECT ADDITIONAL
HOU{[SEWER CONNECTING TO BUILDING OR WORK
PRIVATE DISPOSAL SYSTEM SEPTIC TANK SEEP PIT(S)
CONNECT ADDITIONAL SL[IO OR AND/OR DRAINFI[LD
WORK TO HOUSE S[W[R Q
OVERFLOW SEEPAGE PIT DRAINFI[LD CESSPOOL ❑ ORYWELL ❑
QTN CESSPOOL ORYW[LL MANKOL[0
ALT R D'S OR ABANDON HOUS
ALTER REPAIR SEWER OR
SCW LR OR DISPOSAL SYSTEM SEWAGE DISPOSAL SYSTEM
DISCONNECT PLUG AND
ABANDON HOUSE SEWER
BACKFILL SEPTIC TANKS ❑
{[CP PITIS) El CESSPOOLS
OWNER'S Issuance Fee s
I HAVE READ THIS
AUTHORIZATION TOTAL FEE AND
STATE THAT ACKNODGE THE EABOVEHIST CORRECT AND AGREE TOLICATION CORI
W BTM ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
1
HAVE AT THIS OAT! A CONTRACT WITH THE HEREIN NAMED CON PLUMBING AND SEWERS
TRACTOR TO CONNECT THE ABOVE DESCRIBED CXISTING DWELLING 1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR
TO THE PUBLIC CONN LICENSED AS RIOU ED SY LOS ANGLES COUNTY AND STATE OF
SIGNED THIS DAY OF ID_ CALIFORNIA OR THA 1 AM H[ LEOAL WM[R OF AND INT[HO TO
OW NER OR REBID[ IN THE [ O[ RI RE:
C [t'TIAL ROP6IRY
6WNERS AGENT SIGNATURE
OP P[RMTTT[[
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CN M O CASH
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793-JUL 25 1 0 1) 1 5.0 0 AS6
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