HomeMy Public PortalAbout10011-10011-10011 1/2-10011 3/4 LOWER AZUSA RD_Sewer__ {
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78A APPLICATION FOR PERMIT
76A 6
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL Ifll
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING d L S n
JOHN A LAMBIE. COUNTY ENGINEER ADDRESS ?
COLEMAN W JENKINS SUP T OF BUILDING
LOCALITY
FOR APPLICANT TO FILL IN NEAREST
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(PRINT OR TYPE ONLY)
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DESCRIPTION LOT NO OWNER
MAIL y
BLOCK TRACT ADDRESS /
NO OF BLDG$
SIZE OF LOT NOW ON LOT CITY
USE OF
BUILDINGS DISTRICTNO GROUP CLASS MAP PROCESSED BY
A BK P6
CONTRACTOR
ADDRESS T' CONNECTION DATA
CITY L, TEL NO C S. STATION DEPTH
STATE LICUPPUR
LICENSE NO, OLAss MANHOLE REFERENCE LOWER
NO I DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y CURB PL ML TOP L
PUBLIC SEWER fS DO PC NO '—
SEPTIC TANK SEEPAGE PIT OR CO IMP NO JOB NO
PITS AND/OR DRAINFIELD sl0 00
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO
PRIVATE DISPOSAL SYSTEM $300 d.
CONNECT ADDITIONAL BLDG OR AFFIDAVIT wAIT9R I [ASEMENT RECORD INSTR NO DATE O
WORK TO HOUSE SEWER 33 Do V
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL MANHOLE @ $5 00
IiBBRR•RBPAl"-"ABA NOON HOUSE HWY ORST WIDENING O
SEWER am $300 STATE ENCROACHMENT A
PERMIT NO '�' • O.
INDUSTRIAL h
WASTE APPROVAL Y
OWNERS PERMIT $ 2 OO CHARGES
AUTHORIZATION TOTAL FEE CONNECTION CHARGE PEE
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING ARO
TO THE PUBLIC SEWER •VAJ{a7 DATE INSPEC R S ObSNj
SIGNED THIS DAY OF 18_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT
CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
I HEREBY ACKNOWLEDGE THAT i HAVE READ THIS APPLICATION SEPTIC TANK BEEP PIT(S)
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY AND/OR DRAINFIELD
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR T I AM THE L L OWNER OF AND INTEND TO DISCONNECT PLUG AND
RESIDE IN THE BO CRI SID TIAL ROPE$jY ABANDON HOUSE SEWER
SIGNATURE OF PERMITTEE • BACKFILL SEPTIC TA
SEEP PITS) ❑ C POOLS
VALIDATION JACK R. ALLEN
cK M o CASH SUPERVISING MECHANICAL ENGINEER
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