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APPLICATION FOR PERtf�11T
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SEWER—SEWAGE DISPOSAL
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION
FOR APPLICANT TO FILL IN DISTRICT NO I GROUP BE MAP PS ESSED BY
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PITS ANO/ON GRAINFIELD O CONNECT ADDITIONAL
HOUSE SEWER CONNECTING TO BUILDING OR WORN
PRIVATE DISPOSAL SYSTEM Q SEPTIC TANK BRIEF PIT(IS)
CONNECT ADDITIONAL BLOB OR R
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OVERFLOW SEEPAGE PIT GRAINFIELD CESSPOOL ❑ DRVWELL ❑
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ALTER REPAIR OR ABANDON HOUSE ALTER REPAIR SEWER OR
SEWER OR DISPOSAL SYSTEM 0 SEWAGE DISPOSAL SYSTEM
DISCONNECT PLUG AND
ABANDON MOUSE SEWER
MCKIILL SEPTIC TANKS ❑
SEEP PITISI ❑ CESBPOOLS
OWNER'S Issuance Fee s
1HEREBY ACKNOWLEDGE TNAT 1 HAVE READ THIB APPLICATION
A=01MATION TOTAL FEE AND STAT[ THAT THE ABOVE IS COR.ECT AND AGR[[ TO COMILY
wrc4ALL COUNTY ORDINANCES AND STATE LAWS REODUTIMO
1 HAVE AT THIS DATE A CONTRACT WITH TH( HEREIN NAMED CON FLU Me ING AND SEWERS
TRACTOR TO CONNECT THE ABOVE O[SCRIS[O EIDSTINO OW[LLINO I HERESY CERTIFY THAT I AM PROPERLY R[OISTE AND/OR
TO THE PUBLIC SEWER LICENSED AS REQUIRED BY LOS ANOLU COUNTY AND STAT[ OF
SIGNED THIS DAY OF 1G_ CALIFORNIA OR rH T 1 AM THE LEGAL OWNWR OF AN HTENo To
OWN[ROR RESIDE IN THE VE DESC.m[D w[Slo NTLI STY
OWNERS AO[NT SIGNATURE
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