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BUB.D]XG AND SAFETY DMMON BUILDING
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DESCRIPTION LOT NO OWNER
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USE OF
BINGS DISTRICT NO GROUP BK PO YAP R BY
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CONTRACTO 0 ��
ADDRESS CONNECTION DATA
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STATE MANHOLE REFERENCE J P
REGISTRATION NO 6 COUNTY •>
NO I DESCRIPTION OF WORK FEE
HOUSE
SEWER
EW ERCCONNECTING TOPUBLIC $! 00 G-
TYPE OF CONNECTIOP L LENGTH FROM i)
SEPTIC TANK SEEPAGE PIT OR T CURB Y L TO P L V
PITS AMD OR DRAINFIELD S 00
OVERFLOW SEEPAGE PIT ONA INFIELD
FXTHP RTWE L
HOUSE SEWER CONNECT GTO PC NO
PRIVATE
V E 01 PppO pp�I1��`` 1 CO IMP NO JOB NO M
WORK TO XOUSEISEWEBLDG OR $1.00 TRUNK PERMIT NO ROAD PERMIT NO 8
ALT R REPAIR OR ABANDON HOUSE 1 STATE ENCROACHMENT P°
OR ISPERMIT
INDUSTRIAIAL
W STE APPROVAL
CHARGES
OWNEWS- PERMIT 2 00 CONNECTION CHARGE FEE
AUTHOMATION I TOTAL FEE REIMBURSEMENT FEE L
I RAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR S SIGNATURE
TO TXE PUBLIC 1E11 /
SIGNED THI A OF +9L NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADDRESS SEPTIC TANK SEEP PIT(S)
AMD/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE 13 CORRECT AND AGREE TO COMPLY CESSPOOL DRYWELL
WITH ALL COUNTY ORDINANCE! AND STATE LAWS REGULATING ALTER REPAIR SEWEROR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
IHEREBY CERTIFY THAT 1 AN PROPERLY REGISTERED AND/OR
DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT 1 AY THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDE IAL PR ER TT BACKFILL SE C TANKS
SIGNATURE �j SEEP PIT 9 CESSPOOLS2116
OF PER YI
Or VMMATION-----% ROBERT A WOOD
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