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cAe3° APPLICATION FOR PERMIT
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COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL i
DEPAMEW OSP COUNTY ENGDAF.EB
BUILDING AND SAFETY DIVISION ADILDINa
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USE OF
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SEPTIC T/�NK SEEPAGE PIT OR TYPE OF CONNECTION IS L TO FROM
PITS AXD OR DRAIN FIELD i 00 T CURB P L ■L TO P L
OVENFL W SEEPAGE PIT DPAINFIELD 0 31 00
EXTHOUSE EWER CONNECTINGTO P C NO
P DAAI 77 N1IA�YI� EY CO IMP NO JOB NO
WORK TO XOU9EISE11'ER LDG OR TRUNK PERU IT NO ROAD PERMIT NO -
t&V.l REPAIR OR tBANDON HOUSE OO STATENCROACHMENT
III
PERtlE1T NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNER'S PERMT 2 OO CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE REIMBURSEMENT FEE
I HAVE AT DATE A CONTRACT WITH THETRACTOR TO CIONNECT THE ABOVE DESCRIBED CEREIN ON.MED
a APPROVALS DATE INSPECTOR 3 SIGNATURE
TO THE PUBLIC S
SIGNED THIAY OF B NEW HOUSE SEWER i
OWgER OR CNNECTNG ADORIONAL /
OWNERSAGENT BUOILDIH!WORK
AD DRE SEPTIC TANK SEEP PITS)
AND/OR DgAINF1ELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THI APPA IOM
AND STATE THAT TXfi ABOVE 13 CORRECT S AND AGREE TO OTING CESSPOOL OgTWELL
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR 3EWEROR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT 1 PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS D BY LANGELES COUNTY AND STATE OF
CALIFORNIA ORR THATTHAT THE
1 AN THE LEGAL OWNER OF THE ABOVE ABANDON HOUSE SEWER
DESCRIBED RESIDENTIAL P TY 3ACP PITE C TANKS
SIGNATURE SEEP PITS CESSPOOLS
OF PfiRM
ATION O
ROBERTA WOOD
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