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GA64 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
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OHN A LA14B . County En {Sr Aooxwa
WA JENSEN, Sup I of Building
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No DESCRIPTION OF WORK FE[ PEOFCO N[CTION L O FROM
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1 HAVE AT THIS DAT[ A CONTRACT WITH THE REIMBURSEMENT IEE
TRACTOR TO CONNECT THE ABOVE D[BCR APPROVALS
TO THE PUBLIC 51JfWR_ DAT[ INSPECTOR BSIGNATURE
SIGNED TH 18 J U DAY F W_
OWNERORZ4 [2
NESE HOUSE SEWER
own[Re AGcxr
coxxccr OR WOR AL
BUILDING OR WORK
AODRc[BSEPTIC TANK S[I. PlTlil
IHEREBY ACKNOWLEDGE THAT 1 THIS APPLICATION AHD/OR GRAINFIELD
AND STATE THAT THE ABOVE IB COAGREE TO COMPLYWITH ALL COUNTY ORDINANCES ALAWS REGULATINGPLUMBING AND SEWERSCESSPOOL ❑ DRYW[LL ❑IHEREBYCERTIFY THAT I AM PEGISTERED AND/OR ALTER REPAIR B[W[ROR
LICENSED Ai REQUIRED BY LOS ATT AHD STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT 1 AM TH[ L[OOF AMD INT[XiTORESIDE IN THE ABOVE DESCRI• PROPERTY DISCONNECT PLUG ANO
ABANDON HOUSE SEWER
•IONATUR6BACKFILL B[PTIC TANKSOF PERMITTEEp[SP PIT 161 ❑ CESSPOOLS
VALMATIOROBERT A WOOD
CK M O CASH SUPERVISING MECHANICAL ENGINEER
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