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T6ABAAPPLICATION FOR PE IT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
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DESCRIPTION LOT NO 44 OWNER
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USE 01 Lff�_ MANHOLIE
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REGISTRATION NO REFERENCENO DESCRIPTION OF WORK F[[ EOR CO ION LBNOTH OM /HOUSE OMER CONNECTING TO PL ML TO
PUBLIC EWER C $3,00B[PTIC TANK SEEPAGE PIT OR 7 1 PCNORITS ANO/OR GRAINFIELD EI000NO JOB NOO
HOUSE SEWER CONNECTING TOPERMIT NO ROAD PERMIT N LE
PRIVATE DISPOSAL SYSTEM O SB GO O
CONNECT ADDITIONAL BL ON AFFIDAVIT tmp ..nulN RECORD INSTR NO DAT[
WORK TO HOUSE SMER O 53M
OVERFLOW SEEPAGE PIT GRAINFIELD 6
[ETN CESSPOOL DRYWELL MA NHOL[O SB 00
ALTER R IR OR ABANDON HO HWY on ST WIDENING Z
SEWER ISPOSAL SYS $3 Go STATE CHM[NT
PERMIT NO
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WASTE APPROVAL
OTETRTCIO,s PERMIT s CHARGES
A�I�OIII�ATTON TOTAL FEF 7p coNNccnoN CHARGE PE[
I MAV[ AT THISDATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FE[
TRACTOR TO Co NMLCT THE ABOVE DESCRIBED i LINO ff
TO THE PUBLIC SEWER APPROVALS DAT[ INSPECTOR•SIGNATURE
SIGNED THIS �][�//T///O/ Ig_
OWNER AGENT CONNEW ECT ADDITIONAL OWN ERS AGENT
CONNECT ADDITIONwI
ADOR[SS BUILDING OR WORK
SEPTIC TANK SEEP PIT(G)
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HEREBY ACNNOW LEOO[ THAT I HAV[ RGD THIS APPLICATION AMD/OR GRAINFIELD
ANO STATE THAT THE ABOVE IS CORRECT AND AGR[[ TO COMPLY
WITH
ALL COUNTY ORDINANCES AND STAT[ LAWS REGULATING
FLU MS IND AND SCWEM CESSPOOL ❑ DRYWELL ❑
1 HERESY CERTIFY T T I AM PROI[RLY REGISTERED ANO/OR ALTER REPAIR SEWEROR
LICENSED AS REO" Y LOS AMOLEB COUNTY ANO TAT[ OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR T I M TN[ LEGAL OW OF N NTENO TO DISCONNECT PLUG AND
REBID[ IN THE OV DESCRIBED RES TIA R flTY ABANDON HOUSE SEWER
SIOF FENMITTBACKFILL BE" TANKS ❑
BLEP PIT(,I LI CESSPOOLS
VAMATIOK,--� ROBERT A WOOD
CK M O CASH SUPERVISING MECHANICAL ENGINEER
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GAPPLICATION FOR PERMIT
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COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION 8OLDINSDeG
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LOCALITY
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APPLICANT TO CR°'° 'T
F.Z�:Rl"ILOT NO �� OWMIR�/ IMAILRACT ` MAIL p
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ADDRESS CO CTION DATA
O O O[RN 01 V
CITU
JAUT�ryMANHOLE REFERENCE
R[OISTRATION NO Ie EDWER
No DESCRIPTION OF WORK FEEn ON [NGTH FROd
P[aP
HOUSE 8EW[R CONNECTING TO Y M L TOR L
PUBLIC SKW[R a sow
81"IC TANK SEEPAOt PI RC NO Q
PITS AMD/OR GRAINFIELD Q stow CO IMP NO Joe NO
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT O
PRIVATE DISPOSAL SYSTEM Q $300
CONNECT ADDITIONALO R APPIDAVIT RMY�E �Y�R�Ei RECORD INSTIL NO DAT[ O
WORIITO MOUSEGEWE R Saw OVERFLOW SEEPAGE PIT GRAINFIELD
EETN CESSPOOL DRYWELL MANHOLE Se OO 62
A REPAIR 0 A A Ou HW
N
SEWER OR DItROSAL SYSTEM 11300 • T[ CR ACM M[NT
PERMIT NO
TRIAL
WAS
WAST[APPROVAL
CHARGES
OWNER'S pERNdT IS 2 00
AUTHORIZATION TOTAL FEE CONNECTION CHARD[I[[
1 HAV[ AT THIS DAT[ A CONTRACT W THE HEREIN AM. CO. REIMBURSEMENT ME
TRACTOR TO CONNECT THE ABOVE D[ /[DDWKLLIN
TO THE PUBLIC SEWER APPROVALS ATFy IN PECTOR SSIONAT�IRE
SIGNED THIS AY ID_
OWNER OR NEW HOUSE SEWER
OW N[RB AGENT
CONNECT ADDITIONAL
DOR[/B SU ILDING OR WORK It
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` 1 HEREBY ACKNOWLEDGE THATREADB[IIICTANK SEEP PIT
HAVE READ THIP APPLICATION AND GRAINFIELD
STAT[ THAT TH[ ABOVE Ie CORRECT AND AOR[[ TO COMPLY
WITHALL COUNTY ORDINANCES AND RAT[ LAWS REGULATING
PLU Me IND AND SEWERS CESSPOOL ❑ DRYW[LL ❑
1 HERESY C[RT Y AT I AM PROPERLY R[OI/T[R[D AMO/OR ALTER REPAIR SEWER OR
LICENSED AS R SY LOS ANGLES COUNTY A RATA OF /IWAO!DISPOSAL BY/TEM
CALIFORNIA I AM TME LEGAL OWNER OF A INTEND TO DISCONNECT PLUG AND
R[SIDQ IX E OVC DCSCRIO[ 1°QNT P PIRY ABANDON HOUSE SEWER
SIO NATUR
MITT!! BACKFILL SEPTIC TANKS ❑
0I P[R
6[[P PIT I9) ❑ CbePOOLS
VALIDATION ROBERT A WOOD
c M o cASH SUPERVISING MECHANICAL ENGINEER
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