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AZOOO B-40 _ I 11'-^ ppLIC TION FOR PER
TaaBBaG COVN" OP LOS ANGELES SEWER— SEMI �E
D ART14ENT OF COUNTY ENGm=
UILDING AND SAESTY DIMON eODRES G
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NEAREST
Fo& AFPI ICANT To IN .DROSS 3T
LEGAL c) Y�
DESCRIPTION LOT NO OWNERhi�
BLOCKTRACT MAIL
ADDRESS
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SIZE OF
LOT OF BLDG$OW On LOT :Z.. CITY
USE OF
BUI LO[it DISTRICT NO GROUP MAP PROCLSS
BL PG
CONTRACTOR
ADDRESS !flT/ ECTION ATA
CITY A,-; TEL NO �( ��[ Q STATION 44 DEPTH
REGISTRATION NO
3 �® COUNTY MANHOLE REFE CL
ONE
No DESCRIPTION F WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEVER ® S] TYPE OF ION LENGTH FROM
SEPTIC T NK SEEPAGE PIT OR • URB P L M L TO P L
PITS AND OR DE EPA E PI S]90 T
OVERFLOW SEEPAGE PIT DRAINFIELD r
EXTN
CESSPOOL RYWEL 2 00
HOUSE SEWER CONNECTING TO P 0
PRIVATE i Y f 00 CO YP NO JO 0
CONNECT ADDITIONAk BLDG OR TRUNK PERMIT NO ROAD P0tY1T NO p
WORK TO HOUSE SEWER U
A T EPAIR OR ABANDON HOUSE STATE ENCROACHMENT 03
I DO PERMIT NO
INDUSTRIAL
WASTE APPROVAL
CXAR6
OWNER'S PmWT 2 00 CONNECTION CHARGE FEE
AUTHOaCLATION TOTAL PEE REIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- _
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING AMOVAM DTE INSPECTOR SSIGNATURE
TO THE PUBLIC EWER r- 7
SIGNED THI AY OF 9_ NEW HOUSE SEWER G 041
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR W0RK
ADDRE9 SEPTIC TANK SEEP PIT(S)
AND/OR GRAINFIELD
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION - - - - - - - — -.
ANO STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL DRYWELL 11 )
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS ALTER REPAIR SEWER OR _
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED ARD/OR SEWAGE DISPOSAL SYSTEM
DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA TXT I Y THE LEGAL OWNER OF THE ABOYL
DESCRIBED RESIDENT kL ROPERTY BACKFILL S) IC TANXS
SIGNATURE SEEP FIT
g CESSPOOLE-
OF PERMITTE
mF VAIMATIOROBERT A WOOD
CL ■ 0 faimat I SUPERVISING AIYCHMICAL ENGINKSH _
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