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]pApS6A64ZD APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEEA
BUILDING AND SAFETY DIVISION RA77
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SIGNED THIS DAY OP OWNER OR NEW HOUSE S[W[ROW N[gSAO[NT7CONN[CT ADDITIONAL
[ADDRESS BUILDING OR WORK
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I HEREBY HAT THL[DO[ THAT 1 HAV[ R[AD AND/OR GRAINFIELD
IT IITAT6 THAT TX[ DIVA IE COTTER AMD AOR[H E CMPLYITH ALL COUNTY ORDINANC[H AND /TAT! LAW/ REGULATING
LUMBING AND SLWIRS C¢pIIPOOL ❑ ORYW[LL ❑
1 HEREBY CERTIFY THAT 1 AM PROPERLY R[OIST ED AMD/OR ALTER REPAIR S[W[ROR
ICENSED Ap R[OUBY LOS ANGLE COU O STATE OF SEWAGE DISPOSAL SYSTEM
ALIIORN IAR I AMTHELEGA N[ OF NO INTEND TO DISCONNECT PLUG AND
lBIO6 IN THE O DCBCRIBID [ AL OPERTYAMNDON HOUHE6[WER
IGNATURE / BACKFILL SEPTIC TANKS ❑
OR P[RMI II[CP PIT(f) ❑ CCSSPOOLD
VALIDATION ROBERT A WOOD
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CEeOR 10-03APPLICATION FOR PER IT
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COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEES
BUILDING AND SAFETY DIVISION BUIL
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HOUSE SEWER CONNECTING TO • P L N L TOP a
SEPTIC SEWER d saw PC NO O
PITS A DI.TANPIE PAOC PIT OR IMP NO JOS NO
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CONNECT ADDITIONAL•LDO OR AFFIDAVIT I RAIYTT EAIAXAIIT RECORD INSTR NO DATE
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1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED COX REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS
TO THE PU PLIC SEWER OAT[ I INSPECTORSSIORATUR[
SIGNED THIS-DAY
0 70OWNER OR _
OW X..SAOENT I /// 0 NEW CONNEECTGTHOUA SEWER
ADDITIONAL
ADDR[Ss BUILDING OR WORK
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HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION OT SEEP PIT(B)
AND STAT[ THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY ND/Oq GgAINP16lD
WITH ALL COUNTY OROINA NCES AND STATE LAWS REGULATING
PLUMPING AND SEWERS CESSPOOL ❑ DRYWELL ❑
1 HERESY CERTIFY THAT I AM PROPERLY REOISTCRED ANO/OR ALTER REPAIR SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY wNo AT[ OF SEWAGE DISPOSAL SYSTEN
CALIFOgNIA OR THAT 1 HE LEDAL O R OF AND NT[ND TO DISCONNECT PLUG AND
RESIDE IN THS A ...IPCD R6 TIA PRO RTY ABANDON HOUSE
SEWER
SIOF AP[RMITT[ CKFILL SEPTIC TAN" ❑
9 PIT IS) ❑ CCSPPOOL6 ❑
VAIMATIOROBERT A WOOD
CK M O C>1 SUPERVISING MECHANICAL ENGINEER
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