HomeMy Public PortalAbout10601 LOWER AZUSA RD_Sewer__ :76A 642D CEaoe=,o-7,
APPLICATION FOR, PERMIT.
COUNTY OF LOS ANGELES SEWER—S' .Y/AGE DISPOSAL
DEPARTMENT OFCOUNTYENGINEER.`
BUILDING.AND SAFETY DIVISION BUILDING /�/ £ �/
- - ADDRESS ./V f/�
.. .. LOCALITY
NEAREST - -
FOR APPLICANT TO FILL IN CROSS ST. �
SLE AL
DECRIPTION LOT NO.- - -
C� uT •, � c>,.
-• OW NE .
MAIL
BLOCK TRACT ADDRESS• - �(, �Y`✓d�dl
NO. OF BLDGS. p ` TEL. NO. /^/ aIPROCESSED.By^
- -
SIZE OF LOT NOW 'ON LOT CITY „�A ` �S Y ,1
USE OF -
BUILDINGS - DISTRICT. NO. GROUP. MAP BKPS. e_
CONTRACTOR -.
ADDRESS 'dctJ:{� /� CONNECTION DATA -
CITY `� TEL. NO. 7 " STATION / 7 7 Z 'DEPTH
..STATE' LIC. � , - 1./.
LICENSE NO, j J CLASS MANHOLE REFERENCE LICENSE
d"" / � �' �v - /�7;k LOWER •
NO. DESCRIPTION OF WORK' . .FEE: - .TYPE OF CONNECTION LENGTH FROM. -
HOUSE SEWER CONNECTINGTO - i Y. CURB P:L. M.L.TOP.L.
Q
PUBLIC SEWER - $7.00' • -�� - _ _ - -
SEPTIC TANK,SEEPAGE PIT- OR M.L.
NO.
PITS AND/OR DRAINFIELD @- $10.00 CO..IMP. NO. - JOB NO. -
HOUSE:SEWER CONNECTING TO - - TRUNK.-PERMIT NO. ROAD PERMIT NO. CL
PRIVATE.DISPOSAL SYSTEM @ $3:00 - O
CONNECT ADDITIONAL BLDG.OR - AFFIDAVIT I WAIVER -iASEMENT RECORD..INSTR.NO. DATE V
WORK TO HOUSE SEWER @ -.$3.00 el® - -
OVERFLOWSEEPAGE PIT.DRAINFIELD -
EXTN.•CESSPOOL.DRYWELL,' @'$5.000
-' -
HWY.OR ST.WIDENING
ALTER•REP.AIR,OR ABANDON HOUSE - -
SEWER OR DISPOSAL SYSTEM ;, @ $3.00 STATE ENCROACHMENT _ - _.�. V_
MANHOLE 5 $7.00 PERMIT NO. �� _.�: q(?7.j d
_@ - �.
INDUSTRIAL - -
.WASTE APPROVAL
CHARGES '
EOVMER'S PERMITS
A V T�1HORIZATIOI I7�} TOTAL FEE ®® CONNECTION CHARGE FEE
I-HAVE-AT THISDATE A CONTRACT WITH THE HEREIN NAMEDCON- REIMBURSEMENT FEE
'TRACTOR TO CONNECT THE.ABOVE DESCRIBED EXISTING DWELLING. '
TO THE PUBLIC SE AQRAPPROVALS DATE INSPECTOR'S SI ATURE
SIGNED THI DAY OF 19Z�
OWNER OR - NEW HOUSE SEWER _ _
OWNERS AGENT - a -
-- -_ - - CONNECT ADDITIONAL - ,
ADDRESS t.ti BU I LDING OR WORK
SEPTIC TANK.SEEP.;PIT(S) -
1 HEREBY ACKNOWLEDG H T 1 HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND .STATE THAT THE ABO E`5 'CORRECT AND AGREE TO..,COMPLY
WITH ALL COUNTY ORDINAN ES AND STATE•LA WS REGULATING'
PLUMBING AND'.SEWERS. - CESSPOOL ❑ DRYWELL ❑,
I HEREBY CERTIFY'THAT 1 'A M .PROPERLY REGISTERED AND/OR ALTER:REPAIR.SEWER OR - -
LICENSED AS REQUIRED BY LOS ANGLES COUNTY- AND STATE OF. SEWAGE DISPOSAL SYSTEM - -
CA I-
OR`TH I AM THE LE GAL OWNER OF. AND INTEND Tb� DISCONNECT PLUG AND
RESIDE IN, THE A OVE D ED RESIDENTIAL PROPERTY.: ABANDON HOUSE SEWER - -
.SIGNATURE 'TEE • /„� siL� - BACKFILL SEPTIC TANKS.❑
OF PERMITv' - - '❑
SEEP.PIT(S) -❑ CESPOOLS -
" VALIDATION CK. M.O. .
ASH