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76A642D
CE 808 (REV. 6/78) 1 /79
APPLICATION
FOR PERMIT
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SEWER - SEWAGE DISPOSAL
COUNTY OF LOS ANGELES
BUILDING AND SAFETY
FOR APPLICAN FILL
DISTRICT NO.
GROUP
MAP
PROC ES BY
BK PG
BUILDING
ADDRESS
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CONNECTION DATA
LOCALITY
STATION r DEPTH /
(NEAREST d
CROSS ST.
� U
_
MANHOLE REFER ENCE/ os LOWER
:OWNER
TYPE OF CONNECTION .( LENGTH FROM
,.9 MAIL
Y. CURB P.L. M.L. TO P.L.
ADDRESS ''
P.C. NO. s�
CO. IMP. NO. JOB NO. f
CITY TEL. NO.
r-..
LEGAL
TRUNK PERMIT NO. ROAD PERMIT NO.
DESCRIPTION LOT NO.
AFFIDAVIT
WAIVER
EASEMENT
RECORD. INSTR. NO.
DATE
`. BLOCK TRACT
NO. OF BLDGS.
SIZE OF LOT NOW ON LOT
HWY. OR ST. WIDENING
USE OF
!�: BUILDINGS
STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
:('.CONTRACTOR A ...
WASTE APPROVAL
y
CHARGES
1ADDRESS ,�
e
CONNECTION CHARGE FEE
r�
ST TE /�.� LIC.
LICENSE NO. Fs° ,2p^ CLASS
REIMBURSEMENT FEE
NO.
DESCRIPTION OF WORK FEE
APPROVALS
DATE
INSPECTOR'S SIGNATURE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER
NEW HOUSE SEWER
SEPTIC TANK, SEEPAGE PIT OR
PITS AND/OR DRAINFIELD
CONNECT ADDITIONAL
/
HOUSE SEWER CONNECTING TO
BUILDING OR WORK
DISPOSAL SYSTEM
.PRIVATE
CONNECT ADDITIONAL BLDG. OR
SEPTIC TANK, SEEP, PITIS)
AND/OR DRAINFIELD
WORK TO HOUSE SEWER
OVERFLOW SEEPAGE PIT, DRAINFIELD
CESSPOOL ❑ DRYWELL ❑
EXTN., CESSPOOL, DRYWELL, MANHOLE
ALTER, REPAIR OR ABANDON HOUSE
ALTER, REPAIR, SEWER OR
SEWER OR DISPOSAL SYSTEM
SEWAGE DISPOSAL SYSTEM
DISCONNECT PLUG AND
ABANDON HOUSE SEWER
BACKFILL SEPTIC TANKS ❑
9
O/NE 5
Permit S
)q %�
4` if
SEEP, PIT(S) El CESSPOOLS El
VALIDATION
AUTHORIZATION
TOTAL FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
s = i" i
-: TO THE PUBLIC SEWER.
SIGNEDTHIS DAY OF %9®
1.. OWNER OR
f
_? OWNERS AGENT
.' ADDRESS
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY
\AlITH ALL COUNTY ORDINANCES AND STATE LAWS REGU NG
't PLUMBING AND SEWERS,
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERE AN /OR
=. LICENSED AS RE OU IRED BY LOS ANGELES COUNTY AN STA OF
! CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, P44D I END ORE -
SIDE IN, THE ABOVE DESCRIBED RESIDE IAL P ERT
SIGNATURE --
OF PERM ITTEE `'
FOR D EDAM ENT USE
DU N
INDICATE ALL BUIL',,)INGS ON PROPERTY,
�INDICATE E A'N l ,f/ c NSI{ < � C t icP S
. q��E,.y�'3 t }{E1 E.rg3t� 9 a �dS L_��iE M a'V l�'?}. kp#prl,si M,l��#�
j§ UU
k
SY TEi"A WITH H DISTANCES w O M"JI,DINGS
E
AND PROPERTY UNIES.
4. INDICATE NORTH DIRECT10f',) ON PLOT,
5. IC' ICATEE BOTH STREETS ; IF CORNER,
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FIELD NOTES