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TBA6BAS4APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION DU=
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Oq E88-Y-/l�LL3A`M_ A1�8LOCAUTvFOA APPLI TO CR066 ST lSDESCRIPTION LOT NIf OWNER14 "A" 6 6 NTP i BLOCK TRACT ADOR[66 //�S �}Lk
SIZE OP LOT NOW ON LOT CITY T ldL [L NO Al
USEOF
OUI DISTRICT NO GROUP MAP PROC[ ;By
LOI"Of BK RO
CONTRACTOR
ADDRESS S /9- r1 CONNECTION SPATA
CITY TEL NO [TATION Y DERTH
e STATE LJ UPR[
REGISTRATION NO COUNTY MANHOLE R[F[R[NGC
NO DESCRIPTION OF WORK REE
TYPE OF IOry LENGTH I M /
HOUSE SEWER CONNECTING TO 'R� Y CU R L M L TOR
PUBLIC SEWER @ saw
SEPTIC TANK SEEPAGE PIT OR PC NO
PITS AND/OR DRAINPIELD tl0 00 CO IMP NO JOB NO O
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT N
PRIVATE DISPOSAL SYSTEM SJ DO O
CONNECT ADO ITIONAL BLDG OR AFFIDAVIT PUVv [U[Rui RECORD INSTR NO DATE 0
WORK TO HOUSE SEWER O E300
OVERFLOW SEEPAGE PIT GRAINFIELD
EATR CEBSPOOLORYWELL MANHOLE C 55DO
ALTER REPAIR OK ABANDON HODS[ HWY QRST WIDENING Z
SEWER OR DISPOSAL SYSTEM Y [1 DO BTAM ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
OMFNEWS PERMIT .S $ DO CHARGES
AUTHOREZATION TOTAL FEE CONNECTION CHARD[FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN A"[D CON REIN BU RSEM[NT FCC
"ACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER APPROVALS DATE INSPECTOR IGNATURE
SIGNED THIS DAY OF_10_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION S[PTICTANK SEER PIT(G)
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY AND/OR GRAINFIELD
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEW CRS CESSPOOL ❑ ORYW[LL ❑
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR ALTER N[PAIR SEWER OR
LICENSEDAS REOUIRED BY LOS ANOLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF AND INTEND TO OISCONNCCT PLU
RESIDE IN THE ABOVE DESCRIBED RESIPEKTIAL PROPERTY AND
ABANDON
HOUSESEWER
G AND
SIGNATURE
PERMITTE y/Jn BAC �C TANKS
OF [RML ^✓'2 BEEP PITKFILLISI.EP[IIJ CESSPOOLS
VALIDATION ROBERT A WOOD
cK M O CASH SUPERVISING MECHANICAL ENGINEER
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