HomeMy Public PortalAbout9380 LOWER AZUSA RD_Sewer__ DEPARTMENT OF COUNTY ENGINEER SEWED,-SEWAGE DISPOSAL 1
DIVISION OF BUILDING AND SAFETY PEW IT PLICATION
COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER BUILDING
ADDRESS
FOR APPLICANT TO FILL IN LOCALITY
BUILDING
ADDRESS NEAREST i CROSS ST.
LOCALITY DISTRICT NO. SERIAL N0. PERMIT NO.
NEAREST — AS
CROSS ST.
RECEIVED BY Ready for Inspection DATE ISSUED
OWNER
MAIL
ADDRESS USE ZONE OCCUPANCY MAP
--- � BK PG
CITY TEL•NO.
CONTRACTOR
-- CO.IMP.NO.
ADDRESS ,
JOB.N0.
CITY 7EL.N0. TRUNK PERMIT NO.
Fj STATE
REGISTRATION NO. ❑ COUNTY ROAD PERMIT NO.
LEGAL
DESCRIPTION LOT NO. STATE ENCROACHMENT
PERMIT NO. _
BLOCK TRACT INDUSTRIAL
WASTE APPROVAL
SIZE OF LOT NO.OF BLDGS.
NOW ON LOT CHARGES
USE OF —
BUILDINGS CONNECTION CHARGE FEE
NO. DESCRIPTION OF WORK FEE REIMBURSEMENT FEE
HOUSE SEWER CONNECTING TO —
PUBLIC SEWER $ 3.50 RECEIPT NO. ( DATE BY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.OR ++WEXCEPTION RECORDED
ORK TO HOUSE SEWER I.00
ALTER OR REPAIR EXISTING NO- DATE I BY
SEWER OR DISPOSAL SYSTEM 1.00
Di'SCONNECT AND ABANDON SEWER
_ AMD/OR DISPOSAL SYSTEM 1.00E CONNECTION DATA
SEPT'C TAkK SEEPAGE PIT OR
_ PITS AND/OR DRAINFIELD 2.00 I STATION DEPTH
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 2.00 MANHOLE REFERENCE
Uc.? LOWER
TYPE OF CONNECTION LENGTH FROM
Y- CURB F.L. M.L.TO P.L.
OWNERS PERMIT ; 1 00
AUTHORIZATION TOTAL FEE J
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER
SIGNED THIS----..-----.--.-....DAY OF---.-..-._e________________............is....... 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 ALTER,REPAIR,SEWER OR
REGULATING PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT I 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. BACKFILL SEPTIC TANKS
SIGNATURE SEEP.PIT(S)[] CESSPOOLS❑
OF PERMfTTEE__._..........---------------------_............ ......--....--
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