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COUNTY OF LOS ANGELES SEWER—SEWAGE DISPO
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION ApOREBBUILDINGs
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LOCALITY
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FOR APPLICANT T FII.L CPO68 "
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NO OR BLOCS
SIZE OF LOT XOW ON LOT CITY TEL NO
UBS OF DISTRICT NO GROUP MAP PpOCPJIB[D BY
BUILDINGS
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CONTRACTOR I ✓/ O C
ADDRESS CONNECTION DASA
CITY T[ . Q STATION DEPTH
�5 STAT[ MANHOLE REFERENCE /J I�
REGISTRATION NO ` COUNTY (, (/ / LOWER
No DESCRIPTION OF WORK PE[ TYPE OF CONNECTION LENGTH FROM
HOUSE OMEN CONNECTING TO Y CURS P L ML TOPIL
PUBLIC B[W[R Y {50p
SEPTIC TANK J
CO IMP NO OB NO SIIPAG[PIT ON O NO O
PITS AND/OR GRAINFIELD O {1000
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NOVAE DISPOSAL
CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO
PRIVATE DISPOSAL SYSTEM Q 63M GL
ONX[CT.ADDIT1ONALBLDG OR AFFIDAVIT RUT.. W. RECORD INS" NO O
WORKTO HOUSE SEWER Y [500 r
OVERFLOW SEEPAGE PIT GRAINFIELD IVY
E[TN CESSPOOL ORYWELL MANHOLE C 5500 d
ALTER RCP OR ABANDON HOUSE HWY OR ST WIDENING y,
SEWER OBA SYSTEM i 5500 STATE ENCROACHM6N
PERMIT NO
INWSTRIA
WASTE ROYAL
CHARGES
OWNERS PERMIT s z 00
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE
I HAVE AT THIS DATE A CONTRACT WIT THE HERCIM NAM. ON R[IM[UPBEMEXT FEE.
TRACTOR TO CONNECT THE ABOVE
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TO THE PUBLIC SEWER .,E-,-{QOVAL3 DATE INSPECTOR BBIONAT]RE
SIGNED THIS DAY OF ig_
OWNER OR I� NEW HOUR[SEWER
OWNERS AGENT CONNECT ADDITIONAL
ADDRESS 1� BUILDING O/YMSRR y'f
1 HERESY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION AND/OR GRAANK S[IE PI (S)
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY AND/OR GRAINFIELD
WITH ALL COUNTY 0RGINAN CES AND BTATE LAWS REGULATING
FLU Me IND AND SEWERS CESSPOOL ❑ DRYWCLL ❑
1HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYBTEM
CALIFORNIA OR I AM TME LEGAL OWNER OF AND INTEND TO DISCONNECT PLUG AND
R[SID¢ IN TN VE O[B [SI L PROFCRIY ABANDON NOUBE SEWER
OF PERM BACK PI L SEPTIC TANKS ❑
SEEP PITISI/❑ CESSPOOLS
\IALID ZT ) ROBERT A WOOD
CK M G cAeN SUPERVISING MECHANICAL ENGINEER
LCD 7 3 a 219 NOV 15 1 o D 13.001- q
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