HomeMy Public PortalAbout10635 LOWER AZUSA RD_Sewer__ DEPAIV-rMENT OF COUNTY ENGINEER
SEWER-SEWAGE DISPOSAL .
DYVISION OF BUILDING AND SAFETY PERMIT APPLICATION ^�
COUNTY Off' LOS ANGELES
WILLIAM J. FCX, COUNTY ENGINEER I BUILDING
ADDRESS
FOR APPLICANT JO FILL IN LOCALITY
v
BUILDING NEAREST "
ADDRESSC, CROSS ST.
LOCALITY DISTRICT NO. SERIAL NO. �P'ERM[IT�NO..
NEAREST '? e' /q`? 7`''. yS
OWNS` j(R�EC}�+EIVE{D�tBY Ready for Inspection / DATE ISSUED
r�. �j Y�,YiI�'tej ! W�jj g
MAIL
ADDRESS , ..•, "I/Ll /',G USE ZONE OCCUPANCY MAP
,!j f ! J BK PG
CITY_,14� {JG, TELAO: //-����✓G 7 I /� _" r
CONTRACTOR c
C0::6&lPwNO. Fe 17__5�
ADDRESS JOB NO.
CITY TRUNK PERMIT NO.
q /a ❑ STATE
REGISTRATION N0.j/�C/ '"` _ �-" -CQttNT.1L -
ROAD PERMIT N0.
LEGAL d
DESCRIPTION LOT.NO. L/ STATE ENCROACHMENT
PERMIT NO.
BLOCK TRACT / �/ INDUSTRIAL
WASTE APPROVALS
SIZE OF LOT N0:BF BLDGS. rrJJ `
NOW ON LOT O4• N-11 CHARGES ^
USE OF
BUILDINGS �(�/� w�Er ® 8 CONNECTION CHARGE FEE
NO. DESCRIPTION OF WORK_ FEE
HOUSE SEWER CONNECTING TO _ REIMBURSEMENT FEE
/ PUBLIC SEWER @ $ 3.50 ��' RECEIPT NO. „[]ATE I BY'
,HOUSE SEWER CONNECTING TO J
PRIVATE'DISPOSAL SYSTEM I.00
CONNECT ADDITIONAL BLDG.OREXCEPTION RECORDED
WORK TO HOUSE SEWER .1.00
ALTER OR REPAIR EXISTING „/ANO• I DATE BY
SEWER OR DISPOSAL SYSTEM1.00
DISCONNECT AND ABANDON SEWER ”
AND/OR DISPOSAL SYSTEM 1.00 CONNECTION DATA
,SEPTIC TANK,SEEPAGE PIT OR J
PITS AND/OR DRAINFIELD 2.00 STATION C . 4® Q DEPTH
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 2.00 ' MANHOLE REFERENCE: '
Jzy-&R LOWER
TYPE OF CONNECTION LENGTH FROM'
OWNERS
PERMIT $ I 00y:-�. -CURB- P.L.t_—M.L.TO P.L.
AUTHORIZATION TOTAL FEE
1 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.•- NEW HOUSE SEWER S' OG ���.-s-
CONNECT ADDITIONAL,
OWNER OR • -
OWNERS AGENT---'..,.:. ------------------------------------ ------ BUILDINGORWORK
SEPTIC TANK,SEEP.PIT(S)
ADDRESS------------------------------------------------------------------------------------------ ! AND/OR DRAINFIELD
I'HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLI- CESSPOOL❑ 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. SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED f DISCONNECT PLUG AND ABANDON HOUSE SEWER
AND/OR LICENSED AS REQUIRED.BY LOS ANGELES COUNTY
AND STATE OF CALIFORNIA OR THAT 1 AM THE LEGAL OWN-s
ER OF THE, ABOVE
/DESCCR►IBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS❑
SIGNATURE SEEP:PIT(S)0 CESSPOOLS❑
OF PERMITTEE_-S� '"�c� r�+�''•'�� /�� si/"�6>777
76A642D 663 1/53l �