HomeMy Public PortalAbout10005 LOWER AZUSA RD_Sewer__ r
DEPASTA�iT OF COUNTY ENG� SEWER—SEWAGE DISPOSAL t
DMSION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF 1,08 ANCOCLM
L 81NILLIAM J. FOX, COUNTY ENGINEER AUILDING
DDRESS l0OO
•
FOR APPLICANT TO FILL IN LOCALITY /�
ADORE88 IdOO LO wE/t 1 CR08I3IT G(J /` Arc/eq
LOCALITY / %_ DISTRICT NO. SERIAL N0. PERMIT NO.
CROSS IT 4A' A W/N c� ,j A /y(a/ //Y E I w S
c d RECEIVED BY Roady for laspeetlee DATE ISSUED
OWNER,A:950 dlAlAr AP 01 L bel/ -7—3-- 3
MAIL USE ZONE OCCUPANCYBK MAP P8
ADDRESS
CITY TEL NO. J '
CONTRACTOR r-w �e CO.IMP NO 321 -41
ADDRESS `7I' W aC Af M Br+� JOB.NO
CITY 4A- TEL NO.*L 4C`4*1®g TRUNK PERMIT NO
REGISTRATION NO /Q COUNTY - —
r ROAD PERMIT NO
DESCRIPTION LOT NO V T� PTATE ENCROACHMENT --�
IRMi NO
BLOCK TR �ACT I.,01VA4400/✓p 1 RI114.1 we
-err-it No �—
SIZE OF LOT�0 O X '70NO OF BLOTS BCili y
NOW ON LOT
USE OF
d J c. WOO OO
BUILDDINGS PFS I CONNECTION CHARGE FEE
NO DESCRIPTION OF WORK FEE
'HOUSE SEWER CONNECTING TO , REIMBUEE
RS
PUBLICSEWER 0 $ 860 RECEIPT NO ATE BY
HOUSE SEWER CONNECTING TO
PRIVATE 018POSAL SYSTEM 100
CONNECT ADDITIONAL BLDG OR EXCEPTION RECORDED
WORK TO HOUSE SEWER 100 NO
ALTER OR REPAIR EXISTING DATE BY
SEWER OR DISPOSAL SYSTEM 100
DISCONNEAND AADON
AND/OR DISPOSAL SYSTEM SEWER 100 CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR � Z /
PITS AND/OR DRAINFIELD 2.00 STATION ��/. DEPTH 5S
CESSPOOL—DRY W ELL
SPECIAL CONDITIONS ONLY 200 _ MANH�OOLEE REFEE"W/ /V o/'- LOWER
TYPE OF CONNECTION � �C�NOTH FROM
Y -� CURB P L ✓ M L TO P L
OWNERS PERMIT $ 1 00
AUTHORIZATION TOTAL FEE
1HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER
SIGNED THIS _ DAY OF _ w.._._ - -19 — NEW HOUSE SEWER ' J
OWNER OR CONNECT ADDITIONAL
OWNERS AGEN BUILDING OR WORK
SEPTIC TANK,SEEP.PIT(S)
ADDRESS _ AND/OR DRAINFIELD
CATION AND STATE THAT THE ABOVE 18 CORRECT AGREE CESSPOOL DRYWELL
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER REPAIR SEWER OR
REGULATING PLUMBING AND SEWERS SEWAGE DISPOM SYSTEM
t HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED DISCONNECT PLUG AND
AND/OR LICENSED A8 REQUIRED BY LOS ANGELES COUNTY ABANDON HOUSE SEWER
AND STATE OF CALIFORNIA OR THAT 1 AM THE LEGAL OWN-
ER OF THE AB ESCRIBED RESIDENTIAL PROPERTY BACKFILL PTIC TANKS❑
SIGNATURE SEEP PIT(8)� CESSPOOLS 0
OF PERMITTEE _ _ _ _
70A042D 00 1/66 O .