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6AAPPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION �ooReai
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TRACTOR TO CONNECT THE ABOVE DESCRIBED EEISYING DW
TO THE PU SLIC SEWER APPROVALS DATE INSPECTORS SIGNATURE
SIGNED THIS DAY OF, IQ_
OWNER on NEW HOUSE SEWER
own ERS AGEnT
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ADDRESS BUILDING
G OR WORK
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION S[PTICTANK SEEP PIT(8)
AND STATE THAT THE ABOVE IS CORRECT AND AGREE To COMPLY '(ND/OR GRAINFIELD
WITH ALL COUNTY ORDINANCES AND STAT[ LAWS REGULATING
PLUM SING AND SEWERS CESSPOOL ❑ ORYW[LL ❑
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED ANO/OR ALTER REPAIR SEWER OR
LICENSED AS R[OUIRED BY LOS ANGLES COUNTY AND STAT! OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA on
THAT I AM THE LEGAL OWNER AND INTEND TO DISCONNECT PIUO AND
RESIDE IN THE ASOVE RI SED SID[M ROP[RTY ABANDON HOUSE 0 AND
SIO NATURE
OF PERMITTEE BACKFILL SEPTIC TANKS ❑
BEEF PITIS) ❑ CESSPOOLS
VALIDATION ROBERT A WOOD
cK M o CASH SUPERVISING MECHANICAL ENGINEER
VAC03 3 5 90 JUL 6 1 0 D 7,00-
CES06 10A84 Io-BE APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES
DEPARnfENNT OF COUNTY ENGSEWER-SEWAGE DISPOSAL
INEER
BUWING AND SAFETY DMSION BUILDING 42 Zag,4!
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wooREse pl, .CONNECTION DATA
cin EL NO BTA on DEPTH
REGISTRATION NO COVXTY MANHOLE REFERENCE LOWER
NO DESCRIPTION OF WORK FEE TYPE OF CO N LENGTH FROM
HOUSE SEWER CONNECTING TO Y P L M L TO P L }
PUBLIC SEWER O esoo PC NO O
SEPTIC TANK SEEPAGE PIT OR CO IMP NO JOB NO v
PITS AND/OR DRAINFI ELD C ".GO
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PRIVATE DISPOSAL SYSTEM Q $S co
CON NECT ADD ITIONALBLDG OR AFFIDAVIT R�IE�• �1��R)RL RECORD INSTR NO DATE
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OVERFLOW SEEPAGE PIT GRAINFIELD
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SEWER ORD OaAL SYS M O Sp GO STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
OWNEEVS PERMIT s CHARGER
ALITHORIMTION TOTAL FEE CONNECTION CHARGE FE[
I HAVE AT THIS DAT[ A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED [EISTINO DWELLING
TO THE PUBLIC SEWER APPROVALS DAT( INSPECTOR S SIGNATURE
SIGNED THIS DAV OF 18_
OWNER OR NEW HOUSE SEWER
OW NERS AGE HT
CONNECT ADDITIONAL �
ADDRESS BV ILOINO OR WORN
SEPTIC TANK SEEP PITIS)
1 HEREBY ACKNOWLEDGE THAT I HAVE "MAD THIS APPLICATION AMD/OR DRAINFI[LD
ANO STATE THAT TH[ ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ❑
PLUMBING AND S(WLRS [ANANDON
POOL ❑ DRYWELL f
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/ORR REPAIR SEWER OR /� 1
LICEMBED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OFAGE DISPOSAL SYSTEM II
CALIFORNIA OR THAT 1 AM ( LEGAL OWNER OF AND INTEND TOOn NeCT PLUG AND
RESIDE IN THE AeOV S IDED SIDENTIA ERTY CT PILUOSE A DaIGnATupeOF PERMITTEE FILLSEPTIC TANKB ❑PITfSJ ❑ CfSGPOOLa
ATION ROBERT A WOOD
CN M G cwpH SUPERVISING MECHANICAL ENGINEER
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