HomeMy Public PortalAbout10619 LOWER AZUSA RD_Sewer__ )<DEPA1t7CirlENT OF COUNTY ENGINEER {. SEWER-SEWAGE DISPOSAL
DIVISION OF BUILDING AND SAFETY '; '.
PERMIT APPLICATION.
COU11TTY OF LOS°ANGELES I' e
WILLIAM J. FOX, COUNTY ENGINEER BUILDING,
k.ADDRESS
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7.
FOR APPLICANT TO FILL IN LOCALITY G'
BUILDING / c� NEAREST / /)A
ADDRESS`. / �,��j -,��; 0�Ci-c�jZ t,tt? a, CROSS ST.
///� DISTRICT NO. SERIAL NO. PERMIT,NO.
LOCALITY s+•l�7_lr0 �.
CNEAREST
ROSS ST. ` A 'm 1S
/J RECEIVED BY Ready for Inspection DATEISSUED
0WNER
MAIL ^.0 / �y GZA"-^i t G+G+ `-SCJ /_LPaC
ADDRESS USE ZONE OCCUPANCY. BK PG
MAP
CITY. I•Tay �r'lG.fl LCi4t' TEL:NO. 7 L/✓Ca 7' — l I I l� I y hf '
CONTRACTOR
-EO 11N P.-PIfl.
ADDRESS ���; {I, . � JOB N0.
CITY C-eTEL.NO. v��� �d�f TRUNK PERMIT NO.
STATE '
REGISTRATION NO. �� C �,3 Ca" L7-< egcCOU:NTaS ROAD PERMIT 140.
LEGAL --- CI
DESCRIPTION LOT NO. / SEAMIT NTE ENCROACHMENT _
BLOCK TRACT INDUSTRIAL
WASTE APPROVAL
SIZE OF LOT NO.OF BLOGS.
NOW ON LOT _, ARGES l
'USE OF
BUILDINGS CONNECTION CHARGE FEE/ �.
NO.- DESCRIPTION'OF WORK OE \
HOUSE SEWER.CONNECTING TO REIMBURSEMENT FEE
PUBLICSEWEf3 @ $ 3.50 RECEIPT I DATE' _JBY
'HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1:00.
CONNECT ADDITIONAL BLDG.OR, EXCEPTION RECORDED
WORK TO*HOUSE SEWER 1,00
ALTER OR REPAIR EXISTING. / NO- DATE BY�
SEWER OR'DISPOSAL SYSTEM` 1.00
,DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1_00 CONNECTION DATA
a SEPTIC'TANK-.SEEPAGE PIT OR
PITS AND/OR DRAINFIELD- 2.00 'STATION DEPTH
CESSPOOL-DRYWELL
SPECIAL CONDITIONS ONLY 2.00
MANHOLE REFERENCE
UPPER 1QW
TYPE OF CONNECTIONo- LENGTH FROM
OWNERS, PERMIT $ 1 00 '-CURB (P.L.J M.L.TO P.L.
AUTHORIZATION':I TOTAL FEE Q j
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED,
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING
DWELLING TO THE. PUBLIC -SEWER APPROVALS INSPECTOR'S SIGNATURE DATE
-
SIGNED
SIGNED THIS....................DAY OF- ---.•.-. -_..:-.. .z...19.. NEW HOUSE,SEWER
OWNER- OR CONNECT ADDITIONAL
OWNERS AGENT .............°-....-..........-..............................-- BUILDI,NG OR WORK
ADDRESS _ !� SEPTIC TANK,SEEP.PITS)
- - ----- ---------------- - •! AND/OR DRAINFIELD
HEREBY ACKNOWLEDGE THAT FHAVE READ THIS APPLI CESSPOOL E] DRYWELL D
CATIONAND STATE THAT THE ABOVE IS CORRECT AND-AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER,REPAIR,SEWER OR
REGULATING PLUMBING AND SEWERS. I SEWAGE-DISPOSAL SYSTEM
HEREBY CERTIFY THAT I AM PROPERLY REGISTERED , DISCONNECT PLUG AND
AND/OR LICENSED AS, REQUIRED BY LOS ANGELES, COUNTY ABANDON HOUSE SEWER
AND STATE OF CALIFORNIA OR THAT 1 AM THE LEGAL OWN-n
ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY: BACKFILL SEPTIC TANKS'❑
SIGNATURE -/
�� SEEP:PIT(S) CESSPOOLS
OF.PERMITTEE --- -----•- .,---
76A642D 663, 1/53 R
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