HomeMy Public PortalAbout10217 LOWER AZUSA RD_Sewer__ CE8088.88 !AO V —APPLICATION PERMIT 1
COUNTY OF LOS ANGELES SEWER—SEWAGE ®ISP®SAL.
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS
JOHN A. I.AMBIE, County Engineer
CASSATT D. GRIFFIN.Supt of Building LOCALITY ,
NEAREST
ff FOR APPLICANT TO FILL IN CROSS Sr.
LEGAL OWNER
DESCRIPTION LOT NO.
BLOCK TRACT ? MAIL ADDRESS"/6
NO.OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL.NO.
USE OF k r>
BUILDINGS DISTRICT NO.1 GROUP I MAP PROCESSED BY
BK i PG
CONTRACTOR Able Constr.
ADDRESS 22, W. Bryant Rd. CONNECTION DA A
CITY El MonteCOUNTY TEL.NO. GI 8e STATION � �. 2, � /1 DEPTH
REGISTRATION NO. 168579 STATE MANHOLE REFERENCE. t� UPPER
�
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3.00
SEPTIC TANK,SEEPAGE PIT OR TYPE OF CONNECTION � •LENGTH FROMZY
PITS AND/OR DRAINFIELD @ $3.00 Y. CURB /P L. M.L.TO P.L.)
OVERFLOW SEEPAGE PIT, DRAINFIELD
EXTN.,CESSPOOL,DRYWELL.MANHOLE @ $2.00
HOUSE SEWER CONNECTING TO P.C.NO.
PRIVATE DISPOSAL SYSTEM @ $1.00 CO.IMP.NO. JOB N0.
CONNECT ADDITIONAL BLDG.OR 'TRUNK PERMIT NO. ROAD PERMIT NO.
WORK TO HOUSE SEWER @ $1.00
SEWER OR DISPOSAL SYSTEM PAIR OR ABANDON HOUSE @ $1 00 STATE ENCROACHMENT
PERMIT N0.
INDUSTRIAL
WASTE APPROVAL .
CHARGES
OVERS PERMIT $ 2 OO CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE `— Q� REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. APPROVALS DATE INSPECTOR'S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. --
SIGNED THIS -DAY,OF _19_ NEW HOUSE SEWER T iS �'-y^"-----
OWNER OR b1 ---"� CONNECT
WORKDDAL
OWNERS �!AGENT��` OR
SEPTIC TANK,SEEP,PIT(S)
ADDRESS AND/OR DRAINFIELD
t I HERE13Y,ACtAOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE T4AT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL❑ DRYWELL❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENT L PROPERTY: BACKFILL SEPTIC TANKS❑
SEEP.PIT(S) ❑ CESSPOOLS❑
SIGNATURE o
OF PERMITTEE
®P ALIDATION ROBERT A.WOOD
CK. M.0. CASH SUPERVISING MECHANICAL ENGINEER