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®,4'"% °"E' APPLICATION FOR PERMIT ,
SEWER - SEWAGE DISPOSAL
COUNTY OF LOS ANGELEST BUILDING AND SAFETY
FOR APPLICANT TO FILL IN DL ICT No I SROUP ,YAP , ' q
eN Pc .-BUILDING j{ (� L� NNECTION DATA
LOCISTATH)N' t- L. DEPIIL�aE HT MMHOLEREFERENGBOWNER L+ I ,[NO
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L NO J v
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RIPTION LOTNO
AFFIDAVIT WAIVER EASEMENT "CORD IMBTp NO DATE
K TRACT
NO OP BLDGs
OFLOT NOWONLOT HWY ORST WIDENING 1
OP
INGS STATE ENCROACHMENT
PERMIT HO
RACTOR INDUSTRIAL
WASTE APPROVAL
ESS CHARGES
TEL NO CONNECTION CHARGE PER
E LI RRIMBURSEMENTFEE
NSE NO CLAPS (�
DE CRI"1014 OF WORK Pat APPROVALS DATE INSP[CTORSSIGNATUR
HOUSE SE WER CONNECTING TO /
PUBLIC SEWER /
SEPTICTMR SESPAGEPROR NCW HOUSE SEWER
PITS MD/OR GRAINFIELD CONNECT ADDITIONAL
HOUSE SAW KR CONNECTING TO BUILDING OR WORK
PRNATE DISPOSAL SYSTEM
CONNECT ADDITIONAL BLDG OR SEPTIC GMK.SEEP PIT(S)
WORKTOHOUSEHEWER -- - - AND/OR DRNNRI[LG _ _" "
OVRRPLOW SEEPAGE PIT DRAINPIELD CESSPOOL El DRYWELL❑
6MN C68lPOOL DRYWELL MANHOLE
ALTER REPAIR OR ABANDON HOUSE ALTER REPAIR S[WEROR
SBWER OR DISPOSAL SYSTEM SEWAGE DISPOSAL SYSTEM
DISCONNECT PLUG AND -
MANDONHOUSESEWER
BACKPILL SEPTIC TAN"❑ - - -
Permlt a Soup PIT(s) CESSPOOLS
OWNER'S c -VALIDATION--
AUTHORIZATION -TOTAL FEE" - - — �' ' " ' ' -
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN MARINO COX
TRACTOR TO CONNECT THE ABOVE DESCRIBED P ISJING DWELLING . Z JlAVf1
TOTHEPUBLICSEWER
SIGNEDTHIS '- - DAY OF 1a_ - — — - # a Ya a 10
OWNER OR
OWNERS AGINT - - -- - • - 2 a a_1 BOO
ADDR[aSB
1 HERBY ACKNOWLEDGE THAT I HAVE READ THI3 APPLICATION- '- - a a t 11 1_`-{�
0 0 is
AND STATE THAT THE ABOVE I3 CORRECT AND AGREE TO COMPLY
WITH
aRirHialT�l6 MOHNTY aw ORDINANCESMD STATE "" RETuuTING .]./
o-
_ I 1, -7O
I HEREBY CERTTPY THAT I AM PROPERLY REGISTERED MD/OR G I
LICENSED AS RROUIRSD BY LOS ANGELES OUNTY AND STATE OF
CALIFORNIA OR THAT IAM THE LEOyy,OWN AND INTEN RE
SIGNATURE
IGNAT THE ABOyE DBSGRIBEO B($IDEM PERTY -
SIGNATURE FIG
OfPERMITTEE I