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T0APPLICATION FOft PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION Sm LnING
]]OHN A L�IryM pMvvCounty EB {n ADOREea
WQLLIAtE A. JE7SEN, SDP t of Building
LOCLLIT
NEAREDT
FCL A��PL1 TO cnoee e'LEGAIr
OESCRIPTIOX L TNO of OWNERI I ml �
MAIL
BLOCK TRACT ` ADDRESS
NO OF SLOGS
SIZE OF LOT NOW ON LOT CITY44 TEL NO
USE OF
BUILDING{ J DISTRICT NO I GROUP BK PO O
MAP RC[SS[D By
CONTRACT '
ADORE CONNECTION DAT
CI TEL NO lilSTATION DEPTH
STATE MANHOLE REFERENCE
REGISTRATION NO COUMY 7 %'L7411>4LOWER
NO DESCRIPTION OF WORK FE[ TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y CURS P L MI. TO P L
PUBLIC{EWER Q {B GO PC no 6
IEPTICTw K {E[PAO[PIT ORO
PITS ANO/OR DMA INFIELD O {IO o0 CO IMP NO JOB NO
V
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO
SYS
IRIVAT[DISPOSAL SYSTEM Q $a 00 � /K�
CONNECT ADDITIOXAL BLDG OR APPIOAVIT lM {�RT RECORD INSTR NO DAT[ V
WORK TO HOUSE{EWER Y $S GO r
OVERFLOW SEEPAGE PIT DRAINFIELD ILYJ
[XTN CESSPOOL DRYWELL MANHOLE C $5 00 d
ON HOUSE H R IG NI y
6[W[R A AND[M SSoo STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
OWNER'S PERMIT { a 00 CHARGES
AII 0BMTION TOTAL FEE CONNECTION CHARGE F[[
1 HAVE AT THIS DATE X CONTRACT WITH THE HEREIN NAMED CON R91MOURSEMEW FEE
TRACTOR TO CONNECT THE ABOVE OESCRIB[D EXISTING DWELLING APPROVALS
TO THE
FU ELIC BE DAT[ INSPECTOR S SIGNATURE
SIGNED THIS DAY O 1�
OWNER OR NEW HOUSE SEWER
OWNERS AGENT
CONNECT ADDITIONAL
BUILDING On WORK
ADDRESS
IC I HERESY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION AND/OR
6EE PIT(B)
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY KDn GRAINFIELDILD
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND {EWERS CESSPOOL ❑ DRYWELL (:J
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED ANO/OR ALTER REPAIR {EWER OR
LICENSED AS REQUIRED MY LOS ANGLES COUNTY AND {TATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT 1 M THS L[O OWNER F AND INTEND TO
RESIDE IN THE ABO [BCRItED E IDENTI PROP RTY m
AND
[W[R
SIGNATURE IFOF PERMITTER NKSESSPOOLS
ATION ROBERT A WOOD
cN M O CASH SUPERVISING MECHANICAL ENGINEER
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