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?GASAX APPLICATION FOR PERMIT 1
eAeo° COUNTY OF LOS ANGELES1
DEPArrUn2ff OF COUNTY ENGII�ER SEWER-SEWAGE DISPOSAL
BUILDING AND SAFETY DIVMON AOBDILDI
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LOCALITY
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FOR APPLICANT TO FILL K CRLEAL
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DESCRIPTION LOT NO OWNER
BLOCK TRACT MAA
ADDR
0 OF BLOGS t
SIZE OF LOT NOW ON LOT CITY TEL
USE OF DISTRICT NO GROUP YAP ROCESSED By
BUILDINGS
BK Po
CONTAACTO Q /
ADDRE CONNECTION DATA
CITY 1 L NOWZ Q STATION ^�- 3 DEPTH
ATE MANHOLE REFERENCE J — UPPER
REGISTRATION NO COUNTY LOWER
No I DESCRIPTION OF WORKE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER 1p $S 00 TYPE OF CONNIE LFII GTH FROM -J
SEPTIC TANK SEEPAGE PIT OR T CURB P L ■L TO F L
FITS AND OR DRAINFIEID S 00
OVEREXTNFLOW SEEPACESSPOOLGE P&E RAINFIELD
HOUSE SEWER COSZ 22_
NNOSAI YCTING TO 100 CO IMP NO JOB NO
CONNECT ADDITIONAL BLDG OR TRUNK PERMIT NO ROAD PERMIT NO
WORK TO HOUSE SEWER f
A TER R FAIR OR ABANDON HOUSE fl STATE ENCROACHMENT pl
00 PERMIT NO LpP�rQ9J7
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNws 5 j 00 CONNECTION CHARCE PER
AUTHORIZATION I TOTAL FEE DCop" REIMBURSEMENT FEE
MED CON.
TRACTOR TO CHAVE AT IONNECT THE ABOVE DESCRIBED EKED
ISTIN6S DATE A CONTRACT WITH THE HEREIN ADMELLING APPROVALS DTE IMSPEC "S SIGNATURE
TO THE PUBLIC SEWER
SIGNED THIS----7--D,"OF 19_ NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADORES • AND/ORSEPTIC TANK SEEP DRAINFIELDFIT(D)
I HEREBY ACKNO LEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL DRYNELL
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWEROB
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
I HER EDT CERTIFY THAT 1 AY PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR T T I AY THE LEGAL OW OF THE ABOVE
DESCRIBED RESID IAL PROPERTY BACKFI LL SE CTANKS
SIGNATURE SEEP PITS CESSPOOLS G
OF PERM[TTE
®E VALIDATION SUPERVISING MEECHANICAALOEONGINEM
( ■ a coalI r� //^^ �^
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