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APPLICATION FOR PERMIT 1
�DVISION OF BUUMING AND SAFETY SEWER—SEWAGE DISPOSAL
Depmbnenf of County Englaear E�T �d)
Coady of Loa kylWM J FOX. COUNTY ENGINEERCASSATT O GRIFFIN Sup T OF CIumoma LOCALITFOB APPLICANT TO FILL IN NEBEST
CRLEGAL / A�DESCRIPTION LOT NO {., CF OWNER
BLOCK TRACT 3 MAIL XO OF SLOGSADDRESS ��512E OF LOT 'J CITY Z Irs
USE F /
B ILDOINGS DISTRICT NO GROUP MAP
T PB
CONTRALTO -
ADDRESS CONNECTION DATA
CITY r TEL NoIfl, 12 STATION 6. 56 DEPTH /
STATEM 0 FERENCE
REGISTRATION NO ❑ COUNTY UPPER
TYPE OF CONNECTIO LENGTH FROM
NO DESCRIPTION OF WORK FEE Y CURB P L Y L TO P L
HOUSE SEWER CONNECTING TO -3
PUBLIC SEWER W S 3 30
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1 00
CONNECT ADDITIONAL E BLDG OR p D CO IMP mo/,R -7Z 34UOB NO
WORK C HOUSE SEWER 1 00
ALTER OR REPAIR EXISTING /
SEWER OR DISPOSAL SYSTEM 100 TRUNK PERMIT NO ROAD PERMIT NO V
D ISCONNCCT AND ABANDON SEWER STATE ENCROACHMENT
AND/OR DISPOSAL SYSTEM 1 00 PERMIT NO
SEPTIC TANK SEEPAGE PIT OR
PITS AHD/OR DRAINFIELD 2 00 INDUSTRIAL
CESSPOOL- DRYWELL -- WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2 00 CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT $ 00
AUTHORIZATION TOTAL FEE O REIMBURSEMENT FEE
I HAVECON
TRACTORTTOS CONNECT THEDATE BCTED OVEWITH DESCR BED EXISTINGTHE HERRINA DWELLING APPROVALS DATE INSPECTOR 9 SIGNATURE
TO THE PUBLIC SEWER _ NEW HOUSE SEWER
SIGNED THISIFDAY Dille 1 "�-
OWNER OR G n CONNECT ADDITIONAL /1
OWNERS EXT V.J BUILDING OR WORK
AbORE99 SEPTIINTANK eEEPb IT ISI
ANO/ODRAINFIELD
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ HIE APPLICATION • CESSPOOL❑ DRYWELL❑
ANO STATE THAT THE ABOVE 18 CORRECT AND GREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER, REPAIR SEWER OR
PLUMBING AND SEWERS SEWAGE DISPUAL SYSTEM
1 HEREBY CERTIFY THAT I AN PROPERLY REGISTERED AHD/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON CT PLUG
SEWER
CALIFORNIA OR THAT I AN THE LEGAL OWN F TH6 ABOVE
DESCRIBED RESIDENTIAL P PERTY BACKFILL 8EP C TANKS
EI ❑
BREP PIT a CESSPOOLS
OFr PER E
ERYITTE
WILLIAM J.FOX.4=77Y ENGINEYRVALIDAT�I`ON
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