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6AS4APPLICATION FO PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIMIHIN
euILOING
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191LLU1M A IENSEN SMP t of B.Ud
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FOR APPLICANT TO FILLCRoe8 Sr
O[tICRJIM LOTHO OWNER
MAIL
BLOCK TRACT ADDRESS C
NO OR SLOGS
BILE OF LOT NOW ON LOT CITY TEL NO
USE ` OISTRI CT NO .ROUP BMAP PROCESSED pY
BUILDI..NGS
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CONTRACTOR =' K, //
ADD$eBB ✓✓ V CONNECTION DATA
CITY TEL NO STATION DEPTH
E UPPER
REGISTRATION NO COUNTY MANHOLE REFERENCE LOWER
NO DESCRIPTIO WOR FBH TY [ ON [CTION LENGTH FROM
HOUSE OMER CONNECTING TOY p R M L TO P L
PUBLIC SEWER O [p OO RC XO O
SEPTIC TANK SEEPAGE PIT OR
FITS AND/OR GRAINFIELD SIG Go CO IMP NO JOB NO V
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO
PRIVATE DISPOSAL SYSTEM [300 O
CONNECT ADD ITIONAL BLDG OR AFAIDAVIT WMY[E E41EKExi RECORD INSTR NO PATE
WORK TO HOUSE SEWER O 5300
OVERFLOW SCEPAGE PIT GRAINFIELD
E%TN CESSPOOL DRYW[lL MANHOLE G SS 00 d
ALTER REPAIR O R A pAnDON HO USE HWY OR iT WIDENING Z
SEWER OR DISPOSAL SYSTEM 3300 STATE ENCROACHMENT
P[flMIT XO
INDUSTRIAL
WASTER VAL
OWNER'S PERMIT $ t 00 CHARGES
AUTHOH=TION TOTAL FEE <[ll� CONNECTION CHARGE FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING II Ti}ipO�AiQ
TO THE PUBLIC SEWER APPR DATE INSPECTOR S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE$EWER
OW NERB AGENT
CONNECT ADDITIONAL O
ADDRESS BUILDING OR WORN
SEPTIC
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND//TANK BEEF FIT(S)
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY ANO/OR DRAINFI[LD
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ ORYWELL ❑
1 HERESY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR ALTER REPAIR SMKR OR
LICENSED A$ REQUIRED by S ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM LEGAL OWNER OF AND INTENS TO DIpCOXH[CT LUG AND
SIGMA IN THE AEOV C p D R[SID[NTI L PROFCRTY ABANDON HOUSE SEWER
SIGNATURE
OF
PERM RTEL SAK FILLSED FTANKS ❑
SEEP Flr($) c[e$rooLe
VALIDATION ROBERT A WOOD
cK M o CASH SUPERVISING MECHANICAL ENGINEER
Lj,�0 5 0 0 1;3 OCT 19 1 0 D 5.GO- 4