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7"442a O BO APPLICATION FOR PERMIT
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COUNTY OF LOS ANGELSEWE"EWAGE DISPOSAL 1
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DEPAETMM OF COUNTY ENGUNEES
MWING AND SAFM DIVISION BDILDINc
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NEAREST
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PPLICANT TO FILL IN CROSS BY
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BLOCK TRACTMAIL
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NO OF BLDG!
SIZE OF LOT NOW ON LOT CI ♦ 7cl 0
USE OF
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P/�0CE89ED BT
CONTRACTOR *- �Q 1/ 'R/R
ADDRESS ,�Op- CONNECTION DATA
CITY TEL NO : 3 O ZI STATION t-r-7 35 DEPTH
REGISTRATION NO l STATE MANHOLE REFERENCE
No I DESCRIPTI 4 ON OF WORK FEE
HOUSE 9EWEp CONNECTING TO
PUBLIC SEW @ S DD TYPE OF CONNECTS P L LENGTH FROM
SEPTIC T,{NK SEEPAGE PIT OR T CURB Y L TO P L
PIT!ANDAOR DRAINFIELD
OVERFLOW SEEPAGE PIT DRAINFIELD
E95P00 DRYWEL 00
HOUBE EW ERCONNE ING TO /^ P C NO
PH T DI I CO IMP NO N O JOB NO M
CONNECT ADDITIp NAL BLDG OR TRUNK PERMIT NO ROAD PERMIT NO Q
WORK TO HOUSE SEWER �r V
A AVR
REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
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DISPO1 PERMIT NO Q
INDUSTRIAL aPFpCjj;
-WASTE APPROVAL
CHARGES
OWNERS PERMT 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE Q'Q REIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESC !BED EXISTING ING DWELLING AMOV= DATE INSPECTOR!SIGNATURE
TO THE PUBLIC SEWER
SIGNED THI AY OF 9 NEW HOUSE SEWTR
OWNER OR CONNECT ADDITIONAL /
OWNERS AGENT BUILDING OR WORK Z I3 Gn
-ADDRESS. SEPTIC TANK SEEP PIT(S)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COYPU CESSPOOL Q DRYWEL
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATINGALTER REPAIR SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT I AN PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED A! REQUIRED BT LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE!EWER
CALIFORNIA OR THAT i AM THE L OWN OF THE ABOVE
DESCRIBED RESIDENTIPROPb 1 BACKFILL SE C TANKS
SIGNATURE SEEP PIT
S CESSPOOLS
OF PERMI
®PUMATION ROBERT A WOOD
CL ■ 0 CARR SUPERVISING MECHANICAL ENGIN®t
'LR'L"o 9 6 8 4 E3 DEC 121 0 D 6.00