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76A612D
CE808(REV.6/78)1/79 APPLICATION FOR PERMIT
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SEWER - SEWAGE DISPOSAL
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO FILL IN - - o�sra�cT No. ceouP MAP PROCESSED BY
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-_6K . _ . _ . _._ _ . _ ..
BUILDING �/�
ADDRE55 Q � / � � �C
CONNECTION DATA
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IVEAREST - . . - .. '- '-' .. .." . . STATION-' -� ��[L --' D£PTM - �'-
GRO555T. . ` . _ __ . .._
� �__ ) UP R
MAN E REFTcBTNGE 7 L[� LOW
OWNER pG�
OF GONNECTION LENGTM FROM
MAII `�1�.� {� Y.' CURB P.L M.LTO P.L
ADDRE55 J J� ��
P.C.NO.
CO.IMP.NO. ' JOB NO.
CITY TEL NO.
LEGAL TRUNKPERMITNO. ROADPERMfTNO.
� OESCRIPTION LOTNO.
AFFIDAVIT WAIVER EASEMENT REGORD.INSTR.NO. DATE
BLOCK TRAGT ,
� NO.OF 6LDG5.
SIZE OF LOT NOW ON LOT MWY.OR ST.WIDENING
USE OF
BUILDINGS STATE ENGROAGHMENT
PHRMIT NO.
INDUSTRIAL
GONTRACTf1R WASTE APPROVAL
i ADDRE � GHARGES
� GONNEGTION CMARGE FEE
{ GRr • T L NO. �� �.
ft STATE LIC. REIMBURSEMENTFEE �
r LICENSE NO. CL455 ` Q
NO. OESCRIPTI OF WORK FEE APPROYAW �ATE I 5 R'S NATUR �
'
i HOUSESEWERGONNECTINGTO
PUBLIC SEWER
SEPTIGTAfvK.SEEPAGEPffOR � NEWMOUSESEWER �� O
PRS AND/OR DRAINFIELD CONNECT ADOITIONAL U/
� NOUSE9EWERGOHNEGTINGTO BUILDINGORWORK 6.
PRIVATE DISPOSAL SYSTEM tA
GONNEGT ADDITIONAL BLDG.OR SEP71G TANK.SEEP.PRI5) �
NAORKTO HOUSE SEWER ANO/OR�RAINFIELO _ �
OVERFLOW 3EEPA6E PR.DRAINFIELD GESSPOOL ❑ DRYWELL❑
E%TN..CESSPOOL DRYWELL.MANHOLE
ALTER.REPAIR OR A6AN�ON HOUSE ALTER.REPAIF.SEWER OR � '
SEWER OR DISPOSAL SV3TEM SEWAGE DISPOSAL SYSTEM �
I
- DISGONNEGTPLUG AND - - �� " '
` ABAN�ON HOUSE SEWER
I � BAGKFILLSEPTICTANKB❑ . .
Permit s � SEEP.PRI5)Q CESSPOOLS❑
I OWNER'S VALIDATION
� AUTHORIZATION TOTAL FEE : 1'�5 9,9 A
1 HAVE AT THIS DATE A CONTRAGT WITH THE HEREIN NAMED CON•
TRAGTOR TO GONIVEGT THE ABOYE DESGRIBED EXISTING DWELLING � • F � �,'� O
( TOTHEPUBLICSEWHR. , . .. , ,
E �
� SIGNEDTMIS�DAY OF 1 - - . � � .� y $O C
' OWNEROR
� OWIVERSAG T " . . - M, ,� o � O C�U
U
ADORE55 . � 'q' '
1 HEREBV AGKNOWLEDGE 7HA7 1 HAVE READ THIS APPLICATION ' - U /,0 8�8 0
AND STATE TMAT THE A80VE IS GORRECT AND AGREE TO COMILY
WRH ALL COUNTY ORDINANCES AND 57ATE LAWS REGULATING �
PWMBINGANOSEWERS. � - -
1 HEREBY CERTIFY TNAT 1 AM PROPERLY REGISTERED AND/OR
LIGENSED AS REOUIRED BV LOS ANGELES COUNTY AND STATE OF �
CALIFOpNIA OR THAT 1 AM THE LEGAL OWNER OF.ANO INTEND TO RE• .
SIDE IN.THE ABOVE DESCRIBED RE310ENTIAL PROPERTY. �
� /� / �
SIGNATURE �� /J �/ L `��r "
OF PERMfTTEE ��� '���
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