HomeMy Public PortalAbout10549 LOWER AZUSA RD_Sewer__ �Ek. CRT
C9A042C - AP- PLICATION'. FOR PERM-1T •_
CE808li•S9 -
COUNTY,OF LOS ANEWER—SEWAGE DISPOSAL
DEPARTMEN�ND
OF COUNTY ENGINEER
BUILDING SAFETY DIVISION BUILDING
JOHN'A. MBIE, CounfF'Engsneer ADDRESS ' ✓�5~ r S
CASSATI`D. GRIFFIN, Supt of B,ufIafnq Locpurr CI
NEAREST
FOR APPLICANT.TO FILL IN CROSS ST.
LEGAL.. O�
DESCRIPTION LOT N0. `/ OWNER 6
-TRACT.TRACT. �'J' 7 MALL
ADD ESS,
NO.OF BLDGS.
SIZE-OF-LOT S-61 1010 NOW ON LOT - CITY -TEL. N0. (ZZ.
USE OF
BUILDINGS 44G DISTRICT NO. GROUPBK MAP-.PG PROCESSE Y
CONTRACTOR
Wh
ADDRESS s- . S CONNECTION DATA
CITY TEL.N0. T S STATIONDEPTH
_ STATE MANHOLE REFERENCE
REGISTRATION NO. ® COUNTY / OWER
-No. - DESCRIPTION OF.WORK FEE
HOUSE SEWER CONNECTING TO -
PUBLIC SEWER @ $ .00, t TYPE OF CONNECT LENGTH FROM L�
SEPTIC TANK,SEEPAGE PIT OR ' ' -Y. CURB P.L. M.L.TO P.L. L,J
PITS AND/OR DRAINFIELD @ $ .00 -
OVERFLOW SEEPAGE PIT, DRAINFIELD
EXTN..CESSPOOL.DRYWELL @ .00
HOUSE SEWER CONNECTING TO - P:C.N0.
` PRIVATE DISPOSAL SYSTEM @ $ .00 -aB-'tM'P-NO, 1CLB,.M6.-
CONNECT'ADDITIONAL BLDG.'OR
WORK TO HOUSE SEWER @ $1.00 - TRUNK PERMIT N0. .ROAD PERMIT N0.
ALTER,REPAIR OR ABANDON HOUSE STATE ENCROACHMENT _
SEWER OR DISPOSAL SYSTEM @ 1.00 PERMIT NO. -
�� - INDUSTRIAL
WASTE APPROVAL
ARGES
MUM'S PERMIT $._ Z OO CONNECTION E FEE -. -
`AUTI'I.ORIZATION TOTAL FEE REIMBURSEMENT FEE - -
I HAVE AT,THIS .DATE-A CONTRACT WITH'THE HEREINKA-MED CON.
TRACTOR TO CONNECT THE ABOVE DESCRIBED 'EXISTING DWELLING APPROVALS • - DATE. INSPECTORS SIGNATURE
TO THE PUBLIC SEWER.
SIGNED.THIS DAY OF 19_ NEW HOUSE SEWER
OWNER OR _ _ - CONNECT ADDITIONAL
OWNERS AGENT _ BUILDING OR WORK. -
ADDRESS - SEPTIC TANK,SEEP.PIT(S) -
_ AND/OR DRAINFIELD
1 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 ALT ER,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 I AM_,THE LEGA :OWNER F THE ABOVE
DESCRIBED RESIDENTIAL P OPERTX. ., p BACKFILL SEPTIC TANKS ❑ - '
SIGNATURE
.•SEEP.PIT(S) ❑ CESSPOOLS ❑ -
OF PERMITTE
® y�LWATIO ROBERT A. WOOD
CIL M.o. CASH SUPERVISING MECHANICAL ENGINEER