HomeMy Public PortalAbout10665 LOWER AZUSA RD_Sewer__ IDEPAIVirMENT OF COUNTSENGINEER SEWER-SEWAGE DOSPOSAL
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION I
COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER BUILDING /•"'1
ADDRESS O �
FOR APPLICANT TO FILL IN LOCALITY
BUILDING 0 /'_ - ��� CRO S ST.
NEARES
ADDRESS !/
LOCALITY - DISTRICT NO. p SERIAL NO. PERMIT NO.
A �
NEAREST q /y-- �/ S
CROSS ST. ,.. ,�.G✓ �
RECEIVEDBYReady for Inspection DATE ISSUED
- OWNER
- MAILITRUNK
ADDBK RESS tom- � ,+ t USE ZONE OCCUPANCY MAPPG
CITY GL,�"e, TELAO. 9ln V1
CONTRACTOR / Gd,,",r� r,/Iw�"a CO-&UP—NO.
ADDRESSCITYTEL.NO. Dob No.
,lp PERMIT NO.
REGISTRATION N0. �J ' C. Fl_CAUIN�Y j
ROAD PERMIT N0.
LEGAL
DESCRIPTION LOT NO. PERMIT NNOROACt\ENT
BLOCK TRACT / fZ INDUSTRIAL
FNO.OF BLDGS. WASTE APPROVAL\
SIZE OF LOT NOW ON LOT �CWARGES
USE
BUILDDINGS p��•� ., ��� �� CONNECTION CHARGE F E/\
,rte
NO. DESCRIPTION OF WORK FEE
/ REIMBURSEMENT FE
HOUSE SEWER CONNECTING TO
HOUSE
@ ; 3.50 < � RECEIPT NO. I DATE I 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 B
SEWER OR DISPOSAL SYSTEM IAO
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1.00 CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/ORDRAINFIELD 2.00 STATION't- DEPTH
(/
CESSPOOL—DRYWELLi. I9 q.
SPECIAL CONDITIONS ONLY 2.00MANHOLE REFERENCE
'2 VV r-!I UPPER YO.VMR
TYPE OF CONNECTION LENGTH FROM
OWNERS PERMIT $ 1 00 _Y:-- CURB- P.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-- NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT................... -• BUILDING OR WORK
SEPTIC TANK,SEEP.PIT(S)
ADDRESS---------------------------------------------------------------------------- ------ AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I 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 i ALTER,REPAIR,SEWER OR
REGULATING PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THATRE AM PROPERLY REGISTERED, DISCONNECT PLUG AND
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY,- ABANDON HOUSE SEWER
AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN.
ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. i BACKFILL SEPTIC TANKS
SEEP.PIT(S)[] CESSPOOLS❑
SIGNATURE
OF PERMITTEE ........................... !�
--- _.--._._-- -,.r � -/- � '
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