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APPLICATION FOR PERMIT 7
COUNTY OF LOS ANGELES SEWER--SEWAGE DISPOSAL , 1
DEPARTMENT OF COUNTY ENGINIM
BUILDING AND SAFETY DIMON BUILDINGADDR �SS Val(::1 iiOffi7 1L LAl[B� Com? �y—
CABYAT! D GMff M �t E. rW dWg LOCALITY
FOR APM ANY TO FILL IN "o"ST
LE6AL
DESCRIPTION LOT NO OWMEA r
BLOCK TRACT ADMAIDRESS O'%-V 4NO OF HUGS
SIZE OF LOT NOW ON LOT CITY TEL USE OF
BUILDINGS 1A A DISTAL G"OItP YAP
CONTRACTOR C7
ADDRESS 2 CONNECTION DATA
CITY / TE
L
, NO STATION DEPT"
REGISTRATION NO T 0 OA DUN MANHOLE REFERENCE UPP
no D RIPTION WOR FE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER
SEPTIC T nK SEEPAGE PIT OR TYPE OF CONNECTIO L Y L TO LENGTH FROM
PITS A. OR DRAINFIELD S 00 T CURB P LiA 10
OVERFLOW SEEPAGE PIT DRAINFI LD
EXTN CESSPOOL DRYWELL MANHOLE X 00
HOUSE SEWER CONNECTING TO �+ P C MO
PRIVATE DISPOSAL SYSTEM SI 00 CO IVP NO D JOB NO
CON N ECT ADDITIONAL BLDG OR
WORK TO HOUSE SEWER 1 00 TRUNK PERMIT NO ROAD PERU IT NO
ALTER REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM 1 00 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WA APPROVAL
CHARGES
Owmms PERNIlT 00 CONNECTION CHARGE FEE
AUTHORZATION TOTAL FEE e) REIMBURSEMENT FEE
IHAVE AT THIS DATE A TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTINGWITH THE HEREIN AMED CON DW'ELLING APPROVALS DATE INSP CTOR SSIGNATURE
TO THE PUBLIC SEWER _
SIGNED THI DAY OF 19 NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL -- - "-
OWNERS A6 BUILDING OR WORK
ADO. ANC ORTANK DRAI N Fl EUPITIS)
1 HEREBY ACKNOWLEDGE THAT 1 RAVE READ AIM APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL 0 DRYWELL❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS ALTER REPAIR,SEWER OR
I-HERESY CERTIFY THAT I AM PROPERLr ED AND/OR .SEWAGE DISPOSAL SYSTEM - - - - - — --
LICENSED AD REQUIRED BY LOS AN ELE9 NTY AND STATE OF DISCONNECT PLUG AND
CALIFORNIA OR T 1 AY TH G OWMES OF.7/xJ� ABOVE BANDON HOUSE
ESEWER -
DESCRIBED RESID IAL PROPER SACKFILL9 ICTANK9 rI Irk t
SIGNATURE SEEP PITS CESSPOOL!
OF PERM ZI T�!
ATIOXr1 — ROBERT A W
Cc l 0 Cux/I SUPERVISING MECHANICAL
AL ENOINEER
LD 6 3 4 6 GR NOY 5 '10 A 5.00r-:9