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Aa4 APPLICATI N FOR PERM(T
C EBOO O
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGSEWER—SEWAGE DISPOSAL
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BUILDING AND SAFETY DIVISION FADOR
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FOR APPLICANT TO FML IN TAD[/CRIPTION LOT NO �Q� L (J�BLOCK TRACT O/ J �NOSja
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NO OF SLOGS /'�
•IZ[ OF LOT NOW ON LOT CITY/ TEL NO CJ�. 81:5,15c)
use OF OI{TRICT NO GROUP MAP PROCESSED BY
BUILDINGS
CONTRALTO C O���i � 1 � [/( � l
ADDRESS I L/�/�; CONNECTIO DATA
cl ry(HDC T[L No y�� / /t� STATION DEPTH
REGISTRATION NO B CTAT[COUNTY MANHOLE REFERENCE 5 UPPER
NO DESCRIPTION OF WORK FQE FIC OF CONNECTION LENGTH FROM
/ HOUSE SEWER CONNECTING TO CUR, P L ML TOPIL
PUBLIC{EWER O 69 OO Ofy
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SEPTIC TANK SEEPAGE PIT OR PC
NO DL
FITS AND/OR ORAIXPILLp {1000 CO IMP NO JOp NO _ O
HOUSE/EWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT HO
PRIVATE DISPOSAL SYSTEM C [i 00
CONNECT ADDITIONAL BLVD OR AFFIDAVIT NMY�R [��[RNN RECORD IX8TR NO DAT! O
WORK TO HOUSE SQWER O {i OO F
OVERFLOW SEEPAGE PIT GRAINFIELD {LIJI
EXTN CESSPOOL DRYWELL MANHOLE O $5 OO H\Yy OR 6T WIDENING
ALTER REPAIR Ofl CANDOR HOUSE H
C LBYfTEN N STAT[ENCROACHMENT Z
PERMIT NO
INDUSTRIAL -'— "
WASTE APPROVAL
CHARGES
OWNERS PERMIT s 2 00
AUTHORIZATION TOTAL FEE CONNECTION CHARGE PC6 , J
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON R[IM/URSEMENT FEE
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TRACTOR TO CONNECT THC ABOVE DESCRIBED EXISTING DWELLING •}f}1ROVAlV
TO THE PUBLIC SEWER A" DAT[ INSPECTOR S SIGN TUR
SIGNED THIS DAY OF 18_
OWNER OR NEW HOUSE SEWER
OWNERS A0[NT
CORRECT ADDITIONAL
ADDRESS BUILDING OR WORK
SEPTIC TANK SEEP PIT(S)
1 HERESY ACKNOWLEDGE THAT 1 NAVE READ THIS APPLICATION AMD�OR DIIAINFIELO
AHD STATE THAT THE ABOVE 1{ CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ❑
FLU Me ING AND SEW CNS CL{SPOOL ❑ DRYWELL
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR •LTER REPAIR SEWER OR
LICENSED AS R[OUIR[D BY LOS ANGLES COUNTY AND STAT[ OF SEWAGE DISPOSAL BYSTEM
CALIFOflNIA OR THAT I AM THE LEGAL OWNER OF AND INTEND TO OISLOXNBCT PLUG AND
RESIO[ IN THE A/OV D[SCRIB[ [81 TIAL FROFEI(TY ABANDON HOUSE SEWER
•IO NATURt BACKFILL SEPTIC TANKS
OF PERMITTEE ❑
e"- PIT IS) ❑ CESSPOOLS
VALIDATION ROBERT A WOOD
CN w o CASH SUPERVISING MECHANICAL ENGINEER
_hU04 3 8 4,'_T AUG 5 1 J D 7.00
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