HomeMy Public PortalAbout9352 LOWER AZUSA RD_Sewer__ 7EAE.Gv APPLICATION
FOR PERMIT
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DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL.
Department of County Engineer
County of Los Angeles BUILDING ty
ADDRESS I WM.J. FOX, COUNTY T OF BUEsR « ,CA89ATT D.GRIFFIN,SU P'T OF$lJ(L1�ING LOCALITYFOR APPLICANT TO FILL IN CROSSST LEGat `D£SCR!PT10N LOT NO. t.'- �.�". OWNER �� .
BLOCK TRACT MAIL i- .,
ADDRESS
pO. OF BLDGS. t -
_SIZE OF LOT4 .�' 7 +'4+N OW ON LOT. g CITY TEL. NO.
USE OF I
BUILDINGS i. ..,u �'"'� �•�, ., DISTRICT NO. GROUP MAP
PG
C0NTRACTO
R
—
ADCONNECTION 33.�iTA
DRESS _ — -- ------- -
CITY - v `.. O. '" ,;n- a}r .y STATION _ 7`_'T4 ------ --
rr ~• I +' STATE- MANHOLE REFEREfICE "-
REGISTRATION NO 'y.� r F I�- COUNTY _ LOIMER��
r
NO. ` DESCRI TION OF WORK FEE: -- — - ---- -- - -9
----tt - --- --- -- �+ TYPE OF CONNECTION LF FP �'d it
I'-USE SEWER CONNECTING TO I i ��_ P
PUBLIC SEWER @ $ 3.50 f 'y ,.''✓-+y Y, CJRB P.L. I7 ,�'�O P I _
HOt}SE SEWER
_EO -WEE TO .__
-
__( PRIVATE DISPOSAL SYSTEM 1.00 ..---- ---- --- _._. - ----- -� --
CC dNECT PDD(TICN AL BLDG. OR — -- ---..-- P C NC.
TO HOUSE SEINER _I.GO I CO. IMP. N0._..___`______—_ u
j ALTER OR REPAIR EXISTING
v TRUNK PERMIT NO, ROAD PERMIT NO.
LWFR OR DISPOSALS STEM --_ -1.40 �_.-- _ i .L_
DISCONNECT AND ABANDON SEWERSTATE FNCROACHM ENT
Ah DIOR DISPOSAL SYSTEM 1_00
-PTIC TANK SEEPAGE PIT OR
6ITS AND/OR DRAINF LLD _ 00�.�.- INDUSTRIAL
_ WASTE APPROVAL
CESSPOOL DRYWELL
SPECIAL C014DITIONS ONLY 2.00 CHARGES
1 I v
` llil!•tIT ---� CONNECTION CHARGE FEE
OWNER'S _ �_1_— 3 00
AUT PIOItIZ1TIONTOTAL FEE f Nr.;. REIMBURSEMENTFEEE=
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE �(NS-rCTORS SIGNATURE
TO THE PUBLIC SEWER - - ----- —' — _ `
NEW HOUSE SEWER
`P
SIGNED THIS--DAY OF�
OWNER OR ...,A r8 �� CONNECT ADDITION 11L
C
r UILDING OR WORK
OWNERS AGEN --
SEPTIC.TANK,SEEP, PIT(5)
ANDIOR DRAINFt 't D
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL 0 DRYW"LL 0
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING _ALTER, REPAIR, SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
IHEREBY CERTIFY THAT I AM PROPERLY REG15TERED ANDi CR ----""—'---'--- —� --
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND I
CALIFORNIA OR THAT I AM THE LEGAL OS`dNFAR THF,, ABOL'E ABANDON HOUSE SEL�I;P _
DESCRIBED RESIDEidT1A �ROP�RYY„ rACKFILL SEPTIC TANKS[�
el ;.,. � � SEEP. PIT(S)_❑ CESSPOOLS,[,.I
SIGNATURE
OF PERMITTEE .-:.:.
i t
WILLIAM JwSOX,COUiiTY ENGINEER VAL ATION R.A.WOOD.CHIEF PI-13G. INSPECTOR