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79Ae42o APPLICATION FOR PERMIT ' T MUM OF LOS ANGELPB SEWER—SEWAGE DISPOSAL 1
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No 1� DESCRIPTION 0 WO FEE
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HOUSE SEWER CONNECTING TO P C NO
PRIVATE SI DO CO IMP NO JOB NO
CONNECT�1UD9EISEWEBLDG OR TAUNK PERMIT NO ROAD PERMIT NO
WORK TO IIOU $1.00
A TER REPAIR OR ABANDON HOUSE 1 STATE ENCROACHYEMT
PERMIT NO
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CHARGES
OWNER'S PERMIS 2 00 CONNECTION CHARGE FES
AUTHORIZATION TOTAL FEE - G� REIMBURSEMENT FEE
NAMED COW
TRACTOR TO CONNECTHAVE AT THETHE ABOVE DESCRIBED ES DATE A CONTRACT WITH THE DWELLING APPROVALS DATE INSPECTOR S SIGNATURE
TO THE PUBLIC SEWER �l
SIGNED THIS DAY OF 19_ NEW HOUSE SEWER
OWNER OR / CONNECT ADDITIONAL /
OWNERS AGENT BUILDING OR WORK +r
ADORE / SEPTIC TANA SEEP PIT(S)
AMD/OR GRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I AVE READ LICATION -
AND STATE THAT THE ABOVE IS CORRECT AND COMPLY CESSPOOL ORTWELL
WITH ALL COUNTY ORDINANCES AND STATE ULATING
PLUMBING AND SEWERS ALTER REPAIR 9L SYSEIHEREBY CERTIFY THAT I AN PROPERLY RAND/OR DESCONNEWAGE SPOSALTPLUG SYSTEM
LICENSED AS REQUIRED BY LOS ANGELES COUNT TE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT I AY THE IEGAL OWNLABOVL ABANDON NOUSE SEWERDESCRIBED REBIOENTIALPROPERTYBACKFILL SEPT C TANKS (Y
SIGNATURE SEEP PIT 9 CESSPDOLS 1
F PERMITTEEF
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