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APPLICATION FOR PERMIT - • - 1
COUNTY OF LOS ANGII.88
SEWER-SEWAGE DISPOSAL
DEPARTNaMiT OF COUNTY ENGIIG
BUILDING AND SAFETY DIVIMON eulLmfla
JOHN A. LRMM Cemty Envb w 0 424
ADDRESS
CAmrr D G EFFIN, awt of RRBaRM LOCALITY
NEAST
FOR ANT CROSS BY
LEGAL
DESCRIPTION OIINEfl
BLOCK '�� �'0 ADDRMAIL ESS
NO OF BLDGS
SIZE OF LOT NOW OR LOT CITY TEL NO
USE OF
BUILDINGS DISTRICT NO I GROUP RK MAP -PROCESSED BY
CONTRACTOR V�V' ' ' Lr
ADDRESS CONNECT! N DASA
CITY NO STATION DEPTH
REGISTRATION NO C-4. CONT
UY MANHOLE REFERENCE /
no DESCRIPTION OF WORK FIE
NOOSE SEWER CONNECTING TO
PU LI SAENWERggEEEEpp��L6�gg S 00
PITT AND/OR ORAINFIELDrc OR -SCO TYPE OF CONKEC710 LENGTH FROM Y
��yyEERR pp LL T CURB P L Y L TOP L
FLOW
CESSPOOL DRYIY�LL YANHOLfi° E 00
HOUSE SEVER CONNECTIAG TO P C NO
PRIVATE DISPO SYSTEM 1 0 CO IMP NO Adel V JOB NO
CONRE 7 ApDL�DRy BLD OR TRUNK PERMIT NO ROAD PERMIT KO
CON
T�R 10
Abr OR DICER SAL SYSTEM HOU 1 00 SPATE ENCROACHMENT
PERMIT NO
INDUSTRIAL i
W TE APPROVAL
CHARGES
Os PEOUT2 0D CONNECTION CHARGE FEE
TH
AUORIZATION TOTAL FEE REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON
TRACTOR TO CONNECT THE ABOVE DESCRIBED EKIBTING DWELLING AMOV= DATE INSPECTOR S SIGNATURE
TO THE PUBLIC
SIGNED T Y OF NEW HOUSE SEWER — F
01YNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
SEPTIC TANK SEEP PIT(S)
ADDR AAO R DRAINFIELO
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE 13 CORRECT AMD AGREE TO COYPU CESSPOOL Q DRTWELL
WITH ALL COUNTY ORDINANCES AND MTATE LAWS REGULATING ALTER REPAIR SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTDIED ARD/OR
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATS OF DISCONNECT PLUG AND
CALIFORNIA OR T 1 E LEGA OWNER P THE ABOVE ABANDON HOUSE SEWER
DESCRIBED REST P TY. RACKET
SIGNATOR[ / CESSPOOLS
OF.—
VALIDATION ROBERTA WOOD
ML ■ M. amSUPIRMINO DIMCNANICAL ENGINEER!
A',5 9 8 4S Udi1' 1 1 6 A6,0 0 I