HomeMy Public PortalAbout10229 LOWER AZUSA RD_Sewer__ D_8z
76A6420-62
APPLICATION FOR PERMIT
8A842
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County Engineer ADDRESS
WILLIAM A. JENSEN, Sup't of Building
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST. --
LEGAL ��
DESCRIPTION LOT NO. OWNER
MAIL
BLOCK TRACT ` ADDRESS ' S
NO. OF BLDGS.
SIZE OF LOT N'OW ON LOT CITY N
USE OF � 1
BUILDINGS _ DISTRICT NO. GROUP[ MAP PROCESSED BY /
CONTRACTOR �� � -TV%I `�6 / _ BK
P/ A
ADDRESS y aJ�/))) COCNNNECTI/ON DATA
CITY STATION DEPTH
t°..1 L. O.
❑ STATE //'7 UPPER u
REGISTRATION NO. ❑ COUNTY MANHOL REFERENCE ` `+1/Gie�.�.
CL
NO. DESCRIPTION OF WORK FEE TYPE OF CONNEC LENGTH FROM O
HOUSE SEWER CONNECTING TO Y. CURB P. M.L.TO P.L. (J
PUBLIC SEWER @ $5.00
°
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ $10.00 CO. P. O.'q JOB N O
HOUSE SEWER CONNECTING TO O. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM @ $3.00
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVER I EASEMENTfl RECORD.INSTR.NO. DATE
WORK TO HOUSE SEWER @ $3.00 h
OVERFLOW SEEPAGE PIT,DRAINFIELD Z
EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $5.00
SE=0 �..,.ABANDON HOUSE
HWY.OR ST.WIDENING
SEWER O M @ $3.00 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
OWIVER'S PERMIT $ 2 00 CHARGES
AUTHORIZATION TOTAL FEE CONNECON CHARGE FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIB LISTING DWELLING
TO THE PUBLIC SE . APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS A'Y OF 19
OWNER OR NEW HOUSE SEWER
OWNERS AGENT
CONNECT ADDITIONAL
ADDRESS
BUILDING OR WORK
I
SEPTIC TANK,SEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT IfAAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
1 HEREBY CERTIFY THAT 1 AM PROPERL EGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES O NTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM Al LEGAL O OF, AND 1 TEND TO
T DISCONNECT PLUG AND
RESIDE IN, THE ABOVE DESC IBE R TIRB"R OPER ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMITTEE - SEEP,PIT(S) ❑ CESSPOOLS ❑
VALIDATION ROBERT A. WOOD
CK. M.O. CASH SUPERVISING MECHANICAL ENGINEER
0 0 5 8 SEP 1 1 1 0 Drj.d ISM
24650 INSE�
CE8088.80
76A642D APPLICATION FOR PERMIT pRMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE
DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION TBUILDING �.
RESSL-
IOHN A. LAMBIE, County Engineer i
WILLIAM A. JENSEN. Supt of Building ALITY
REST
FOR APPLIC NT TO FIL, " ss SI 6)
LEGAL }
DESCRIPTION LOT OWNER /
�✓
BLOCK - TRACT MAIL/bf ADDRESS d25 �/
NO.OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE DISTRICT NO. GROUP MAP OCESSED BY
BUILDIDINGS _ � BK PG
CONTRACTORiY
ADDRESS V - CONNECTION DATA
CITY TEL.NO. �- STATION DEPTH i
ESTATE MANHOLE REFERENCE UPPER
REGISTRATION NO. � � �•o[� ❑ COUNTY 6
No. DESCRIPTION OF WORK FEE
SEWERHOUSE CONNECTING TO
PUBLICSEWER@ $3.00
TYPE OF CONNECTIO LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR Y. CURB :L. M.L.TO P.L.
PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT, DRAINFIELD
EXTN.. CESSPOOL. DRYWELL @ $2.00
HOUSE SEWER CONNECTING TO P. .
PRIVATE DISPOSAL SYSTEM @ $1.00 CO. IMP. N0. JOBB NO.
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT NO. M
WORK TO HOUSE SEWER @ $1.00 V
SEWER OR DISPOSAL SYSTEM HOUSE @ $1 00 STATE ENCROACHMENT Phi
PERMIT N0. O
,INDUSTRIAL V
WASTE APPROVAL µt
CHARGES UI
OWNER'S PERMIT $ 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE c REIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECT,OR'S SIGNATURE
r TO THE PUBLIC SEWER. (
SIGNED THIS DAY OF 19_ NEW HOUSE SEWER ij ,r9tC' 'dam z rf.✓ y2 .._/-
OWNER OR CONNECT ADDITIONAL r
OWNERS AGENT BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PITS)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION
AND STATE THAT 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 1 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
BACKFILL SEPTIC TANKS ../ .-.- '-
DESCRIBED R ID Ip P OP RT ❑
/ SEEP.PITS) ❑ CESSPOOL P �/YIJLI •f-���''.7..6'c�'
SIGNATURE
OF PERMITTE
®F VALIDATION ROBERT WOOD
CIL lit
C .o. (CASH SUPERVISING MECHANICAL ENGINEER