HomeMy Public PortalAbout10625 LOWER AZUSA RD_Sewer__ " Mf COUNTY. ENGINEER SEWER®SEWAGE. DISPOSAL
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES J
- WILLIAM J. FOX, COUNTY-ENGINEER BUILDING
I ADDRESS /�.(o � r�Q /,//l'.'.A
FOR APPLICANT TO FILL IN- LOCALITY \fi e 6e^ r
BUILDING NEAREST + /� p
ADDRESS �DG -LI >L r�/ YSteRelFGit CROSS ST.
LOCALITYi DISTRICT NO. SERIAL-No. l PERMIT NO.'
NEAREST . ! A F`9J !• "^"-q5
CROSS ST.
RECEIVED BY Ready for Inspection 'DATE ISSUED
OWNER t/ / -/6MAUL -7J� .s .
ADDRESS L^y ': USE ZONE OCCUPANCY MAP
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CITY TEL.NO. {
CONTRACTOR ,
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ADDRESS ]
JOB NO.` �!
CITY /TEEL'.NO. TRUNK PERMIT_ N0.STAT
REGISTRATION_O. 1/J (�/ J - -�iz EQUNTY
- ROAD PERMIT�NO. •
LEGAL
DESCRIPTION LOT NO. { 'STATE ENCROAC"ENT
PERMIT NO.
BLOCK' TRACT, INDUSTRIAL
Fr NO.OF BLDGS. WASTE APPROVAL
SIZE OF LOT NOW-ON LOT
1 CHARGESUSE OF
BUILDINGSCONNECTION CHARGE FEE_
NO. DESCRIPTION OF WORK FEE \
\
HOUSE SEWER CONNECTING TOREIMBURSEMENT FEE
PUBLIC SEWER @ $ 3:50 i RECEIPT N0. / DATE �I BY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
CONNECTADDITIONAL BLDG.OR J EXCEPTION RECORDED
WORK TO ROUSE SEWER 1.00 I
ALTER OR REPAIR EXISTING NO- ( DATE L BY`\
SEWER OR DISPOSAL SYSTEM 1.00 /
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1.00 CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 2.00 STATION DEPTH �.
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 2.00 MANHOLE REFERENCE
UPPER LSLINER
TYPE OF CONNECTIONLENGTH FROM
OWNERS PERMIT $ -G"B• rP"l-,� M.L.TO P.L:
AUTHORIZATION TOTAL FEE
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 THIS--- :__-,DAY OF ------ -------- -,-_19-.W__; NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT-_...... -•----•-----------•--------••---•-•------••-• ------ BUILDING OR WORK
s SEPTIC TANK;SEEP.PIT(S)
ADDRESS - -- - - AND/ORDRAINFIELD
t
I HEREBY ACKNOWLEDGE THAT I,HAVE READ THIS APPLI- CESSPOOL F].DRYWELL'�
CATION AND 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. ALTER, REPAIR,SE SYSTEM
1 HEREBY CERTIFY THAT I AM PROPERLY •REGISTERED"'� DISCONNECT PLA AND
AND/OR LICENSED AS REQUIRED BY LOS-ANGELES COUNTY . ABANDON HOUSE SEWER
AND STATE OF CALIFORNIA OR THAT 1 AM THE LEGAL OWN-
ER OF THE ABOVE DESCRIBED RESIDENTIAL.PROPERTY. BACKFILL SEPTIC TANKS '
`�QSEEP.PIT(S)Ej CESSPOOLS❑
SIGNATURE
OF PERMITTEE-. ,--:_. },
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