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GE808(REV.6�7B)1/79 APPLICATION �FOR PE RM IT
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SEWER - SEWAGE DISPOSAL
� COUNTY OF LOS ANGELES BWLDING AND SAFETY
FOR APPLICANT T FILL IN ��iHICT NO. GflO1JP MAP PROCESSED BY
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BUILDING � J .� �`` G
ADDRESS / ��< <Y'
CONNKTION DATA
j LOCAUTV /}
� NEAFEST - - . - . . .. STATION.� 7 ..._ . .�EPTH � -. . _ - .. . -. . -.
CROSS ST. �Y
7 .a9' s�v ow R
MANM ENCE
OWNER PE OF CONNECTION LENGTH FROM
I MA�L ��' Y. CURB P. M.LTOP,L
ADDRESS
� P.G.NO. ✓�
� CO.IMP.NO. J08 NO. .�
CITY �(i� TEL NO.
� TRUNKPERM�TNO. ROADPERMITNO.
LE6AL
I DESGRIPTION LOTNO. `
� BLOCK TRACT � `J' fJ�J / AFFIDAVR WAIVER EASEMENi REGORC.INSTR.NO. DATE
NO.OF B�DGS. ,
'i SIZE OF LOT NOW ON LOT - MYJY.OR 5T.WIOENING -
� USEOF
UUILDINGS � STATE ENGROACHMENT
PERMIT NO.
� � INDUSTRIAL .
CONTRACTOR WASTE APPROVAL
ADORE 5 (J CHARGES
! GITY ' � ELNO.- O CONNEGTIONCHARGEFEE
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ISTATE IIC. REIMBURSEMENT FEE 0'
LIGENSE NO. � CLA55 �� O
NO. DESCRIPTION OF WORK FEE APPROYALS DATE INSP I NATURE U
HOUSE SEWER CONNEG7ING TO �
PUBLICSEWER � �
SEPTIC7ANK.SEEPAGEPITOR NEWHOUSESEWER � O
PITS ANO/Ofi DRAINFIEID GONNEGT ADDITIONAL � L'J
� HOUSE SEWER CONNEGTIIVG TO BUILDING OR WORK C.
PRIVATE DISPOSAL SYSTEM ,SEPTIG TANK.SEEP,PfT1$1 z
CONNECTADORIOfVAL BLDG.OR AND/OR DRAINFIELD
WORKTOHOUSESEWER - - �
OVERFLOW SEEPAGE PIT.DqAINFIELD GESSPOOL � DRYWELL❑
EXTN..CESSPOOL.�RVWELI.MANHOLE
ALTEF.REPAIR OR ABANDON HOUSE ALTER.REPAIR.SEWER OR
SEWER OR DISPOSAL SVSTEM SEWAGE DISPOSAL SYSTEM
DISCONNECT PLUG ANO
ABANDONMOUSESEWER
BACKFILLSEPTICTANKS❑
SEEP.PRISI� CESSPOOLS❑
OWNER'S Permit s
AUTHORIZATION TOTAL FEE VALIDATION � r 6 9.8 A
1 HAVE AT TNIS DATE A CONTRACT WRH THE HEREIN NAMED CON- .. +l� � • • � O
TRACTOR TO GONNECT THE ABOVE DESGRIBED EX�STING DWELLING � .
TOTHEPUBLICSEWER. ' ' ' '
SIGNEDTHIS�DAY OF 19�� � . t� ° � �I�S.O O
OWNER OR , � ��O U
OWNERS AG T � e e e '
ADDRESS
1 HERE6Y ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION a��O�L�O
ANU STATE TMAT TME ABOVE IS CORREGT AND AGREE TO COMPLY
WRH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PWMBING AND SEWERS.
t I HEREBV CEFT�FV THAT 1 AM PROPERLY REGISTERED AND/OR
LICENSED AS REOUIRED BY LOS ANGELES COUN7Y ANO STATE OF
CALIFORNIA OR TNAT 1 AM THE LEGAL OWNER OF,AND INTEND TO RE-
SIDE IN,THE ABOVE DESCR�BED RESIDENTIA�FiROPE
i1GNATURE �
OF PERMITTEE
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