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"SOB SOB& u APPLICATION FOR PERMIT
s • COUNTY OF LOS ANGII.EB
SEWER SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGRG=
BDII.DBVG AND SAFETY MI ION BUILDING
IC.
YORK A. LACounty Swb wr ADDRESS
CAMTr D afaQrDv. BMD•(of Building LOCALITY
NEAREST
OR APPLICANT TO W cuss By
LEGAL _
DESCRIPTIONLOT NO f OWNER
BLOCK TRACT _ PAIL
ADDRESS
NO OF BLDGS
NUS
OF LOT NOW ON L TEL NO
E OF
BUILDINGS DISTMICTNO GROUP YAP P P SED BT
CONTRACTOR • • _
ADDRESS 1517 COLEGROVE AVECONNECTION DATA
Cm QEL No PA. 1-5048 STATION DEPTH /
REGISTRATION NO 18OT61 TE pp n MANHOLE BVEREMCK
NO RIPTIO W R FEE LOITER
yHgOUSE /EEM'pgCEOENMEQCgTINGTO a� O }
PITS SND/OR ORAI NFIEI IT
OR TYPE 0!CONNECTIO LENGTH FROM
T CURB L M L TO P
OVERFLOW SEEPAGE PI7,D VANE Q 00
EKTN CESSPOOL DR
HOUSE SEWER CONNECTING TO P C NO.
PRIVATE DISPOSAL SYSTEM I DO CO IVP fl0 10B NO
CONNECT ADDITIONAL BLDG OR TRUNK PERMIT NO ROAD PERMIT NO
WORK TOO HOUSE SEWER 1 00
EEN OR DI�P09Ri1L SSj'NOEO�HOUSE T � STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
RAST AP
CHARGES
OWNER'S PEBDSIT 2 OD CONNECTION CHARGE
ADTHOHIZATION TOTAL FFS REIMBURSEMENT FEQ
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN HAYED COB APPAQV DATE INSPECTOR d SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EKI IM DWELLING
TO THE PUBLIC 9
jr
SIGNED THI F Iy,�Q NEW xouSE seRml ��
OWNER OR CONNECT ADDITIONAL
DITHERS AGENT BUILDING OR WORK
ADORES SEPTICTANK SEEP PITS)
AN OR DWNF1ELD
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION
AMD STATE THAT THE ABOVE IS CORRECT AND AGREE TO COYPU CESSPOOL DRTWELL
WITH ALL COUNTY ORDINANCES AND !TATE LAWS REGULATING ALTER REPAIR 9E'REfl OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
I HEREBY LICENSED A9CER REOUT TNA LOS A GE T N7Y ANR STATE/OF D011 ISCONNECT PLUG AND
CALIFORNIA OR TX 1 AM IR OF Ana ABANDON HOUSE SERER
DESCRIBED RE81D AL BACKFI LL SE CTANKS
DIGNATURE
ESCRIBED CE39 LS
OF PERYI
VALIDATION ROBERT aWOOD
MM. ■ w MAMM 6WIFIRVUBING BIMCISABIICAL MBIwNYlt
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APPLICATION FOR PERMIT ,
aROB.B u
COUNTY OF L08 ANGELES SEWER-SEWAGE DISPOSAL
DEPASTBEENT OF COUNTY ENGINEE8
EDII.DING AND SAFETY DIVISION BUILDING
' JOEM A. LUMIX County Zmwh c ADDRESS
casaRTT 1). GMIFFM BuP•t of BGBabw LOCALITY
NEAREST
FOR APPUC O FIM By CROSS ST
LEGAL
[REGISTRATION
CRIPTION NO OWNER
C[ MAIL
ADDRESS
NO OF B
OF LOT No
ON Np
OF
LDINGS JOOY
TRICT NO GROUP BAP PROCESSED
BY
TRAC70H BN PG
S 1511 COUGROVE CO ON TA
TEL NO i HATION t O. DEPTH
NO 180767 STAANHOLE REFERENCE UPPER
DESCRIPTION FEE LOWER
PUBLIC SEWER CONNECTING TO
aaEPfIC T MEER9EEPAGgg PIT ORTYPE OF CONNECTION LENGTH FROM
PIT9 AND OSREDERAI NFIETLD L CURB P L Y L TOPL
°�RFLOWN POOL URYWELL YNXOLED HOUSE SEWER CONNECTING TOPCNOPRIVATE DISPOSAL SYSTEM IMP NO O JOB NOCONNECTADDITIONALLBUNK PERMIT NO ROAD PERMIT NO
WORN TO ROUSE SEWER ALTER ppEPAIR OR ABANDON HOUSEATE ENCROACHMENT
SEWER OR DISPOSAL SYSTEM RMIT NO
DUSTRIALAST PPROCHARGES
OWNES•S EMIT ONNECTION CHARGE FEE
ADTHOBI7ATION I TOTAL FEE O REIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON APPSOVALS DATE INSPECTOR S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EEISTING DWHLLIMO
TO THE PUBLIC SEWE MN cccc 0000
SIGNED THISAY 1 xEW HOUSE SEWER -
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT ING OR WORN /L
ADDRRfn SEPTITAN CNK SEEP PIT($)
AND ORAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL Q DRTWELL 171
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
1 MEREST CERTIFY THAT I AM PltOPVnMLI REGISTERED AM DISCONNECT PLUG ARD
LICENSED AS REQUIRED AMC UNIT D STATE OF ABANDON HOUSE SLEEK
CALIFORNIA OR THAT PAY T HER 0 THE ABO
DESCRIBED RISIDEHT RO BACKFILL SEPMC TA NNS
13BIGRANRE SEEP PIT (S)
LS 01 1
OP FERMI
®� /--YALROBERWOOD
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MPMHYIl/G MECHCK ANICAL ENGINEER
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