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70A 642D APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE 14SPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION eulLolno e
JOHN A LAMBIE COUNTY ENGINEER "DDREES
COLEMAN W JENKINS SUPT OF BUILDING
LOCALITY
NEARER
FOR APPLICANT TO FII.L IN CROSS ST
LEGAL
DESCRIPTION LOT NO OWNER
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LICENSE NO CLA tt L.� LOWER
No DESCRIPTION OF W RK M. TYPE OF CONNECTION L NGTN ROM
NOUS[tEW[R CONNECTING TO Y CURB P L M L TO L
-Pullm SEW" a ss Go SEPTIC TANK PAD[PIT OR P C NO
P9.AND/OR ORAINPIQLD flo oo CO IYP NO JOB NO
HOUSE SEWER CONNECTING TO. TRUNK PERMIT HO ROAD PERMIT ND
PRIVATE DISPOSAL SYSTEM s3oo O
CONNECT ADDITIONAL BLOO M AFFIDAVIT RMYIR IA...IRT RECORD IN/TR NO DATE ()
JyGYY.To HOUSE SEWER a $3 GO
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OVERFLOW 9E8PA0!PIT ORAINFIILD Q
[ETN CESSPOOL DRYWfLL MANHOLE G t!GO HWY OR R WIDENING
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ALTER REPAIR OR ABANDON HOUSE W
SEWER OR DISPOSAL SYQTCM f300
STAY CMCROACHYLRT 1
PERMIT NO i
INDUSTRIAL
��T[T�p� WASTE APPROVAL
O YTl\Lll S CHARGE{
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AUTHORIZATION TOTAL FEE ( CONNECTION CHARD[I[[
1 HAVC AT THIS DAT[ A CONTRACT WITH TAC HEREIN NAMED CON RLIM/URSKM[NT FE[
TRACTOR T4 CONNECT THE MOV[ D[/CRIBIO REIRINO DWELLING APPROVAL)
TO THE PUBLIC BCW[R DAT! IMNCRORSSIGNATUR[
SIGNED THIS DAY OF 19_
OWNER OR NEW NOUS({EWER
OWN LRS AGENT
CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
1 M[RCBY ACKL. A
THAT 1 HAVE READ THIS APPLICATION SEPTIC TANK {!IE PIT I[1
ARD/OR GRAINFIELD
AND tTATE THAVE 1/ CORRECT AND AGREE TO COMPLY
WITH ALL COUNTYRANGES AND STAT[ LAWS REGULATING
PLUMBING AND CESSPOOL ❑ DRYW(LL ❑
I M(R[/Y CERTIFY I AM PROPERLY RLDIR(R[D ANO/OR ALTER REPAIR t[W[R OR
LICQNS[D AS RY LOS ANGLE/ COUNTY AND {TAT[ OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THE LEGAL OWNER OF AND INTEND TO pIBCONNECT PLUG AND
REBID! IN THRI/LD IDE L PROP[
ABANDON HOUSE SEWER
• T
{IGNATUR[
OF PGM BACKFILL SEPTIC TANKS ❑
S(CP PITI[1 ❑ C[S[POOLS
41 VALIDATION JACK R ALLEN
cn M D CMH SUPERVISING MECHANICAL ENGINEER
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