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ESOB36' APPLICATION FOR PERMIT
TSABA2D COUNTY OF LOS ANGELES IIJJ
DEPARTMENT OF COUNTY ENGINEER SEWER-SEWAGE DISPOSAL
MENNEN
BUILDING AND SAFETY DIVISION eu1Lo1NG �M r
WMALAMSIE Couply Epqqu[p{[r AODpeae
WILLIAM A IZKM SQP f d suildmy SL
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FOR APPLICANT TO FILL IN CROS{ ST
L L
DESCRIPTION LOT NO 57Y OWNER
MAIL
BLOCK TRACT ADDRESS
NO OF {LOOS
SIZE OF LOT NOW ON LOT CITY TEL XO
USE OF DISTRICT OROUF MAF WE559D SY
pUILOIN08
e PO
CONTRACTOR
ADDRESS CO CTION DATA
7 STATION DEPTH
CI TEL NO ./
STAT[ YANHOLS REFERLNC[ UPPER
RIGIaTRATIO HO LINTY LOWER
NO DESCRIPTION F WORK FEE TYPE OF CONNECTION OTH FROM
HOUSE SEWER CONNECTING TO Y CURa P L M L TO P L
PUBLIC SEWER Y s500 PC NO
SEPTIC TANK SEEPAGE PIT ORCO INP NO JOB NO
PITS AND/OR DMINFI[LD ® SI000
HOUSE SEWER CONNECTING TO TRUNK MIT NO ROAD KRMR NO
PRIVATE DISPOSAL SYSTEM 0 s3 o0
CONNECT ADDITIONAL SLOG OR AFFIDAVIT • 4E[uRl RECORD INSTR NO OAT[
WORKTO HOUSE SEWER O s300 /
OVERFLOW SEEPAGE PIT GRAINFIELD
E[TN CESSPOOL ORYWELL MANHOLE Y S°00
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING
SEWER OR DISPOSAL SYSTEM 5300 STATE OACHM ENT
PERMIT NO
INOUSTRIAL
WASTE APPROVAL
OWNER'S
PESNI7 s tS
AUTHORIZATION TOTAL FEE CONNECTION CHARD[F[[
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTORTO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS
TO THE PUBLIC SEWER DAT[ INSPECTORS{IONATUR!
SIGNED THIS DAY OF IB_
OWNER OR NEW HOUB[BEWER
OW NEWS AGENT
CONNECT ADDITIONAL
AGGRESS BUILDING OR WORK
SEPTIC1 HAND/OR
EREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION O TANK SEEP PIT(G)
AND STAT[ THAT THE ABOVE 12 CORRECT AND AGREE TO COMPLY ANO/ GRAINFIELDWITH ALL COUNTYORDINANCES AND STATE LAW{ REGULATING
PLUMBING AND SEWS RS CESSPOOL ❑ DRYWELL ❑
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED ANO/OR ALTER REPAIR SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STAT! OF SEWAGE DISPOSAL SYSTEM
CALI PORNIA OR THAT I AM THE LEGAL OWNER OF AND INTEND TO DISCONNECT PLUG AND
RESIDE IN E ABOVE DEBLRISED SIO[NT PROPERTY ABANDON HOUSE SEWER
SIGNA Ri BACKFILL SEPTIC TANKS ❑
OF P MITTE6 STEP PIT(S) ❑ CESSPOOLS
VALIDATION ROBERT A WOOD
\ CK M o cAeH SUPERVISING MECHANICAL ENGINEER
J
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9 7 2 IG JAN 16 1 0 0 5.0 0- v