HomeMy Public PortalAbout9346 LOWER AZUSA RD_Sewer__ 41
76A642 D-64 APPLICATION FOR PERMIT ` ^
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COUNTY OF LOS ANGELES SEWER-SEWAGE DIS SAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County Engineer ADDRESS )-e; ;7-14
WILLIAM A. JENSEN. Supt of Building A
LOCALITY ...NEAREST
FOR APPLICANT TO FILL IN `ROSS BT.SS LE
DESCRIPTION LOT NO '' e Yr+ -CL_ �- OWNER ¢'"BLOCK TRACT ADDRESS `ti3gf ..
�-^ NO. OF 8LDG5.
SIZE OF LOT ,J cl j` i�i' NOW ON LOT_ � CIT
USE OF �r -
9UILDINGS — - ---- - DISTRICT NO. ROUP MAP PROCESSED BY
BK PG
CONTRACTOR "" M, -. " • �r C+ � '4
ADDRESS b -- — r't: CONNECTION DATA - ----
CITY 1 TEL. NO. A STATION DEPTH
S'. -
TE MANHOLE REFERENCE UPPER-
SGiSTRAT N NO. _COUNTY � �_ Jew>•
NO. UESCRIPTI N OF WORK FEE TYPE OF CONNECTION LENGTHI ROM
HOUSE SEWER CONNECT[NO TO Y. CURB P.L, M.L.TO L.
PUBLIC SEWER @ ;5_00 P.C.NO - !'
SEPTICTANK,SEEPAGE PIT OR - JOB NO. +� �
•CO. IMP.NO. O
PITS.4NDl OR DRRINFIELD @ $10.00 � � -' �
HOUSE SEWER CONNECTING TO
j ; i TRUNK PERMIT NO. ROAD PERMIT NO. CJ
PRIVATE DISPOSAL SYSTEM $3.00
N NECT ADDITIONAL BLG.DAFFIDAVIT I WAIVER 1 1*51M141 RECORD.INSTR.NO. DATE
GT
.:7111101111if--7O HOUSE SEWER @ 763.00 3 O
OVERFLOW SEEPAGE PIT,DRAINF1ELD
EXTN__ SPOOL,DRYW ELL,MA NH OLE @ $5.00 I LU
ALTER,REPAIR OR ABANDON HOUSE - HWY.OR ST.WIDENING a.CID
SEWER OR DISPOSALS $3.00 _--_".-_
_--_ _ STATE ENCROACHMENT ,f
PERMIT NO. .J'- �a� .l z
— ---- --- INDUSTRIAL J? , '"'1 ! �-•\#t-`
WASTE APPROVAL
OWNERS PERMIT $ 2 OO CHARGES
-- � CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE i `� "'47 - - - -
'I HAVEAT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DE RISED� EXISTING DWELLING APPROVALS -
TO THE PUBLIC SEW R. it 'I� b DATE INSPECTO -4 SIGNATURE
SIGNED THIS "•DP:. OF 19 '--'---"--- �- ,�*q•
OWNER OR }' A.
NEW HOUSE SEWER (& y
OWNERS AGENT
_ CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS - i,•y f --� — SEPTIC TANK,SEEP,PiT(8) #
IH
ACKNOWLEDGE THAT I HAVE READ THIS PPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE dS CORRECT AND AGREE TO COMPLY -- ---
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND./'OR ALTER,REPAIR,SEWER OR -
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER F. AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE A S1[ DE CRIBS RES) NTI F�. PROPERTY.PE RTY ABANDON HOUSE SEWER
SIGNATURE (� �7 --i
OF PERMITTEE-- - "_ 4u`d•%'t' a,5 BACKFILL.SEP[I TANKS ❑ �.
SEEP,PIT(S) ❑ CESSPOOLS ❑I.
VALIDATION ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
•� CK. M.O. CASH