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TSA 0420 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DIS OS L
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION F.C.
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JOHN A LAMBIE, COUNTY ENGINEER u J w
COLEMAN W JENKINS SUPT OF BUILDINGTY
N RARER
FOR APPLICANT,TO FILL IIi GRoss BT
DESCRIPTION LOT NO _ OWNER
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MAIL
BLOCK TRACT I f ADDRESSNo or
SI[[ OF LOT 1 NOW ON LOTS CITY TEL NO 97 0 ( /
YS6 OF DISTRICTNO ORO MAP PROCESSED SY
■UILDINOS __ 1 S K y
CONTRACTOR � F C I D (1
ADDRESS Z 4 �ove` YP CO CnON DATA
CITY Cc TCL NO J j 8D STATION I DEPTH
STAT[ D LIC MANHOLE REFERENCE J UP
LICKNS MO S CLAS[ J
NO DESCRIPTION OF WORK PEE TYPE OI N
LENGTHFRO
HOUSE SEWER CONNECTING TO Y CUR• P L M L TOP L
PUBLIC pQWU O tp 00 CO
PITS AND/OR
[LADE PIT OR / P C NO
PITS AND/OR OflA1N11lLO 0 tl0 Op CO IMP NO .IOp NO �
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO
PRIVATE DISPOSAL SYSTEM O t)00
CONNECT ADDITIONAL SLOG OR AFFIDAVIT RSRII .fa[aa R[CORp INQTR NO DA CDU
WORN TO HOU6[6[WLR Y t)OO
OVERFLOW SEEPAGE PIT GRAINFIELD
E[TN CESSPOOL ORYW[LL MANHOLE O tp OO CD
ALTER REPAIR OR ABANDON HOUSE XWY OR ST WIDENING W
SEWER OR DISPOSAL SYSTEM O 53M STAT[ENCROACHMENT D.
PERMIT NO i
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT s z o0
AUTHORMTION TOTAL FEE O CONNECTION CHARGE IEE CHAROU
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON RCIM SURS[MQNT IE[
TRACTOR TO,CONN[CT THE ABOVE D[SCHIp[D EIISTINO DWELLING APPROVAL)
TO THE PUBLIC [EWER DA 7E, INS CTOR SSI ATUR6
SIGNED THIS DAY F IS_
OWNER OR NEW HOUSE SEWER
OWN[RSAO[NT� 1�
CONNECT ADDITIONAL
ADDRESS pU1LDING OR WORK
eCPTICTANK BER PIT(G)
HEREBY ACKMOW LED6E THAT I HAVE READ THIS APPLICATION AND/OR DRAINFI[LD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STAT[ LAWS REGULATING
PLUMSIND AND SEW ERB CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OltALTER REPAIR SEWER OR
LICENSEDAS REQUIRED BY LOS ANGLES COUNTY AND STAT[ OF S[WA GE DISPOSAL SYSTEM
CA LIPORN IA OR THAT I AM TH! LEGAL OWNER OF AND INTEND TO DISCONNECT PLUG AND
R[61D[ IN THE ABOVE CR RESIDENTIAL PROPERTY
ABANDON HOUSE SEWER
SIGNATURE
OF P[RMTTT[ BACKFILL SEPTIC TANKS ❑ L
LEEP "
ITIpI ❑ C[bPOOLQ i
VALJACK R ALL N
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CK M O GASH SUPERVISING MECHANICAL ENGINEER
L4r,. 2 9 3 a-� DEC 2 1 0 0 7.00-