HomeMy Public PortalAbout10241 LOWER AZUSA RD_Sewer__ ,63 APPLICATION FOR PERMIT" [�
f 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. Supt of Building
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CRGBS ST.
LEGAL
DESCRIPTION LOT NO. ,� a- OWNER
MAIL
BLOCK TRACT ADDRESS
NO. OF BLDGS.
SIZE OF LOT /�_>NOW ON LOT CITY `. TEL. NO.
USE OF DISTRICT NO. GROUP MAP PROCESSED BY
BUILDINGS /per^-+/1 ,y/ ��/�t�
�'� 1 'T. BK f e .'"VEv
CONTRACTOR ♦
ADDRESS ` (, es CONNECTION DATA
%1STATION DEPTH
CIT)' /(�' TEL. NO. O
STATE UPPER
MANHOLE REFERENCE LOWER
REGI TRATI NO. �'
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTIONLENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L.
PUBLIC SEWER @ $5.00
/\P.C.NO.
SEPTIC TANK,SEEPAGE PIT OR OB NO. O
PITS AND/OR DRAINFIELD @ $10.00 CO.IMP. NO.
V
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. / ROA PERMIT NO.
PRIVATE DISPOSAL SYSTEM @ $3.00 IIX
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVER EASEMENT RECORD, IN R.NO. DATE O
WORK TO HOUSE SEWER @ $3.00 G V
OVERFLOW SEEPAGE PIT,DRAINFIELD l!J
E%TN„CESSPOOL,DRYWELL,MANHOLE @ $5.00
ALTER,REPAIR OR ABANDON HOUSE HWY.OR ST.W E G H
SEWER OR DISPOSAL SYSTEM @ $3.00 STATE E ``R H
PERMIT Wt 7
INDUSTRIAL
WASTE APPROVA L ,�
CHARGES
OWNERS PERMIT $ z 00
AUTHORIZATION TOTAL FEE 0,1040 CONNECTION CHARGE FEE
'I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED ON. REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS SEPTIC TANK.SEEP,PITS)
I HEREBY ACKNOWLEDGE THAT I HAVE 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 ❑
I HEREBY CERTIFY THA I PROPER Y REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSED AS REQUIRED B LO ANGLES DUNT•Y-AN. STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM L OWNR OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABOVE DE RI ES1D�N IA PROPERTY. ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMITTEE SEEP,PIT(S) ❑ CESSPOOLS ❑
G CALIDATION ROBERT A. WOOD
} SUPERVISING MECHANICAL ENGINEER
M.O. CASH
Ll�il,J l7 �.� ��c 8 10 D 5.0 0-- .
;-
7CIA842D _ APPLICATION: FOR PERMIT-- ,, . - -
S f E-663 11=55
DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL ,
Department of County Engineer
- ' County of. Los Angeles BUILDING l
,JOHN A. LAMBIE. COUNTY ENGINEER ADDRESS •,/:
® '. CA'SSATT D:GRIFFIN',SUPT OF BUILDING LOCALITYAl
'
FOR APPLICANT TO FILL IN CROSS ST: t> ��- -_e�t.
LEGAL• ' /p _
DESCRIPTION LOT,NO, j •"'.� I OWNER
i MAIL
'
BLOCK TRACT it J jil , ADDRESS
/NO. OF BLDGS. CITY ,TEL. N0. -
SIZE OF LOT NOW ON LOT - '
USE OF- - O.DISTRICT NGROUP MAP
7
BUILDINGS - I - .
e BK. PG-
CONTRACTOR
ADDRESS O CONVECTION DA
"�t
STATION DEPTH'
CITY iEl:. NO � L7 b � MANHOLE R C , UPPER •
`r .. LOWER _( .
REGISTRATION N0.` /,D J .f/- 7dOUNTY
WI
N0'. DESCRIPTION OF WORK FEEHOUSE SEWER CONNECTING TO TYPE OF CONNECTION 'LENGTH FROM
PUBLIC SEWER @ $3.50 Y. CURB P.L. M.L. TO P.L. -SEPTIC TANK,SEEPAGE PIT ORR 1- -PITS AND/ODRAINFIELD Q $3.00OVERFLOW SEEPAGEPIT,DRAINFIELDEXTN•,CESSPOOL,DRYWELL-,MANHOLE Q $2.00CO. LMP.:NO.
'HOUSE SEWERCONNECTING TO - - I
PRIVATE DISPOSAL SYSTEM Q _$1.00 TRUNK PERMIT NO. OAD PERMIT
CONN ECT'ADDIT I ONAL BLDG.OR STATE ENCROACHMENT.
WORK TO HOUSE SEWER Q $1.00 --1 PERMIT NO.
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
'SEWER OR DISPOSAL-SYSTEM - `Q $1.00 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE ..
OWNER'S PERMIT g 1 00
AUTHORIZATION TOTAL FEE 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. . NEW HOUSE SEWER
SIGNED THIS, DAY OF 19 CONNECT OR
f
OWNER OR: - - _ BUILDING OR WORK ._ Jjl„f;;�. r"Za •;�
OWNERS 'AGENT- SEPTIC TANK,SEEP,PIT(S) 1
ADDRESS AND/OR DRAINFIELD - -
I HEREBY,ACKNOWLEDGE THAT IHAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL�
AND STATE THAT THE ABOVE IS.CORRECT AND AGREE TO COMPLY - -
WITHALL COUNTY ORDINANCES AND STATE' LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. - I SEWAGE.DISPOSALSYSTEM. ;
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 I AM THE LEGAL .0 R. OF THE ABOVE -
'DESCRIBED RESIDENTIAL PROPE.TY.��J BACKFILL SEPTIC TANKS C3 -
� /� 2(`/„ SEEP.PITS)Cl CESSPOOLS❑ -
SIGNAT �1/URE - _
OF`PERMITTEE" - - -
JOHN A. LA'MBIE: COUNTY ENGINEER VALIDATION ROBERT A. WOOD: CHIEF PLEIG. INSPECTOR
_ M.0 CASH _