HomeMy Public PortalAbout10653 LOWER AZUSA RD_Sewer__ -DEPAICTMENT OF COUNTY ENGINEER SEWER—SEWAGE DISPOSAL
DIVISION=-OF BUILDING AND -SAFETY
PERMIT APPLICATION.
COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER BUILDDRESSDING
I A
LOCALITY ,
FOR APPLICANT T�,rO,1�FOILnL IN - �(�'�.�n� �t�-" �. C��.
BUILDING / /S / ^'j •- pe"' �++ Y lw /,i �. .CROSS NEAREST.
ST
ADDRESS f CJ 4 J LC'/l�S
LOCALITY C� (/ w DISTRICT NO. SERIAL N0: Vit; }PERMIT'N0.
NEAREST
CROSS ST: t A
RECEIVED BY Ready for Inspection ' DATE ISSUED
OWNERMAIL
.
ADDRESS / � S . USE ZONE OCCUPANCY MAP -
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CITY h+ttiY7(r_ -N
TELO. �'�'J G 4� _ / I
CONTRACTOR
ADDRESS ag/,, clQ+dl r
CITY [% > '. y✓ TEL.NO. TRUNK PERMIT-NO:
p+� STATE
REGISTRATION NO. 1� �,r1 "' �o �( CO,UitTYy"
ROAD PERMIT N0.
LEGAL
DESCRIPTION LOT NO. STATE ENCROACHMENT
PERMIT NO.
BLOCK TRACT , INDUSTRIAL
WASTE APPROVAL \
SIZE OF LOT NO.OF BLDGS.
NOW ON LOT CHA'66ES
USOF
BUELDINGS - T�r.�-st' CONNECTION CHARGE FEE' \
NO., DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
REIMBURSEMENT f
PUBLIC SEWER @ $ 3.50 RECEIPT NO. I DATE, BY
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 I DATE, I BY
SEWER OR DISPOSAL SYSTEM 1.00 i
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL.SYSTEM 1.00 CONNECTION DATA'
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/ORDRAINFIELD 2.00 STATION fhGa DEPTH �p /
CESSPOOL-DRYWELL
SPECIAL CONDITIONS ONLY 2.00 MANHOLE REFERENCE r
F.rxAL G LOWER
TYPE OF CONNECTIONLENGTH FROMV e�-1
OWNERS PERMIT $ 1 00, C_y_ C1PRB P.L. �. M.L.TO P.L. ,>
AUTHORIZATION I TOTAL FEE �g )
.1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMER.
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING. APPROVALS INSPECTOR'SSIGNATURE DATE
DWELLING TO THE PUBLIC SEWER L/ f
SIGNED TH IS--------------------DAY OF--------------------------------.......19__" NEW HOUSE SEWER Get Y'®fsl 'sL
OWNER- .OR CONNECT ADDITIONAL
OWNERS AGENT---------------------------------------............................... BUILDING O R.WORK
ADDRESS------------------------------------ SEPTIC TANK,SEEP.PIT(S)
..................•............ AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLI CESSPOOL E DRYWELL❑
CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO COMPLY WITH ALL COUNTYORDINANCESAND STATE LAWS ALTER,REPAIR,SEWER OR
REGULATING PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY; DISCONNECT PLUG AND
AND STATE OF CALIFORNIA OR THAT 1 AM THE LEGAL OWN= ABANDON HOUSE SEWER
ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS O
^ SEEP.PIT(S)o CESSPOOLS[-]
SIGNATURE
OF PERMIT TEE.-• ---�-I FW
76A642D 663 1/532 '