HomeMy Public PortalAbout9388 LOWER AZUSA RD_Sewer__ :E808 10-63
6A6420 APPLICATION FOR PERMIt'
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION [C-,
L I_.D;NG
JOHN A. LAMBIE, County' Engineer
ASS -=
WILLIAM A. JENSEN, Sup't of Building
O:A L T Y
—_
ERRE T
FOR APPLICANT TO FILL INRoss ST
DESCRIP ION LOT NO ='.� �' r; OWNER
:."/_... .MAIL
BLOCK TRACT \ :. - _ iADDRESS
NO. OF SLOGS. -
SIZEOF LOT NOW ON LOT CITY TEL. NO.
OF
BUILDINGS GS _ � f "- �;— DISTRICT NO, GROUP MAF PROCESSED BY
BK P.-.
CONTRAC 'O --'0
ADDRESS `" CONNECTION DATA
s _y'` > STATION y� DEPTH
CITY vJ.f 0 'i TEL NO. .�' °''*_ J (L`
ATE
REGISTRATION Nu. _ COUNTY MANHOLE REFERENCE a LJ
-- — — - /"SIC/c
NO. i GESCftIP'T 10. Or tNORY. rEE PEF ,�NECTION - -_-- --LENGT%FROM �K
PUBLIC SEWER
HOUSE SEWER CONNECTING TO � � Y. ,,f;(,�$�tB P.L. M.L.TO P,L.
( - !., E•��bdd�dd.�����"�v>3=�^
_ L- d _
SEPTIC TANK !;E PAGE PIT OR "'�---�' '- P.C.NO.
! CO. IMP. NO. ''-`� JOB NO '
7$ANE7f OR DRAINPIELD $tO.OD
HOIJ SE SEWER GON NECTING TO TRUNK PERMIT NO AS
ROAD PERMIT O. a
PRIVATE DISPOSAL SYSTEM $3.00
CONNECT DD 'ONA�BLDG OR 1 AFFIDAVIT WAIVER j EanKM NY 1--RECORD,INSTR NO. DATE
WORK TO HOUSE SEWER $3.00 --
- 2
: ..VERFI.OW E'E'r AGEP(T.DRAINhtE'LD L 1.,�..'_ a'i
i
EXT N..CESSPOOL.D-----L;MA NH OLE Q .$5.00 e
___. ___-_ ___. __-_-.__-_-_,,_—��.-. HWY.OR$T.WIDENING
ALTER.REPAIR OR ABANDON e(QU$E I
1 SEWER OR DsSPOSAL SYSTEM
_- _.-.
PERWT NO.
INOU STRIAE
WASTE APPROVAL r :.. U.
CHARGES
.y�OWN�RpR'S PERMIT --� z 00
AUTHORIZATION TOTAL FEE_. CONNECTION CHARGE FEE
'! HAVE: AT THIS DATE A CONTRACT WITH 'HE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO C)NNECT Tii£ ABOVE DESCRIBED EXISTING DWELLING Ci .--.-_-
TO THE FUBI_!C SE"A'ER, APPROVALS —r_ DATE INSPECTOR 5 SIGNATURE.
y. - — -- — -
SIGNED THIS,-----,DAY -
OWNER OR NEW HOUSE SEWER f
OWNERS AGENT__________. CONNECT ADDITIONAL -_-
T 6 ILDING OR WORK
ADDRESS
SEPTIC TANK,SEEP.
HEREBY ..
ALK OWLED, E Tfi A.T HAVE READ TH!S APPLICATION AND/OR DRAINFIELO I I
AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY ......
WITHALL.. COUNTY ORC.'iNANCF, AND STATE i..AwS RCGUI_4TING
PLUMBING AND SEWERS. CESSPOOL DRY'WELL LJ
HEREBY CERTI E ,
Y THAT AM PROPERLYq REGISTERED AND/OR ALTER.REPAIR,SEWER OR
1_1'CENSE D AS Rr_QUI RED. BY LOS. ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALITORN-A OR THAT 1 AM THE LEGAL. OWNER OF, AND INTEND TO DIS ONNECT PLUG AND - T-_---� -----� --_--�--
RES'DE N, THE ABOVF._..?ESC R.IBED RESIDENTIAL P PERTY
- !! Ri ABANDON NOUCL SSE,VER
SIGNATURE
BACKFILL SEPTIC TANKS j _----
OF PERMITTEE -_-
SEEP,PiT(S) L CESSPOOLS QI
M VALIDATION ROBERT A. WOOD
,y' SUPERVISING MECHANICAL ENGINEER
J CK. j M.Cl- CASH
.�a
'E808 10-63
6A642G APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER SEWER-SEWAGE DISPOSAL
BUILDING AND SAFETY DIVISION HULDING
JOHN R. LAMBIE, County Engineer ADDRESS
r
WILLIAM A. JENSEN, Sup'4 of Building
LOCALITY CAL -.
-
-
NEARE
FOR APPLICANT TO FILL IN CROSS ST
[SIZE
--___ _._. ----.--
LEGA/.
DE.SCRI P'iION LOT no. ,.,`.;_ .-. .: .-/
"i` OWNER
MAIL
BLOCK "f; ADDRESS
NO. OF SLOGS.OF LOT •b - NOW ON LOT CI'i'Y TEL..NO.
USE OF
DISTRICT , GROUP MAP PROC E55ED By
C O NT RA CTnta -,ifi,a+_ ._ �y - BK U - -
44v-5
ADDRESS, ___
CONNECTION DATA
4, ,gy STATION DEPTH -
C17Y _ T. Nr f ev �,"' J -
STATE
: ? J „yr!"" MANHOLEREFER E CE -_
REGt5TRA710N NO t COUNTY r 'LOWE
NOT GuS ftfPT•t0114-0F WORK_.`_@-S5
E `.— — _—. __— —._ —_ :4.
_ `�' _ TYPE OF CONNECTION LENGTH FRom !w�ryry
1
HOUSE SEWER CONNECTING TO_ --- Y CURB P L M.L.TO P-L.
PUBLIC SEWER _ v $6:,Do �.L Y'---- P.C.No.
_---
SEPTIC TANK.SEEPAGE PIT OR s
CO._IMP. NO. .` � .;OB NO.
PITS AND VR DRA NFIELD � SIC,00 - _-Y_-
---i HOU5E.SEWPRC ON NECTING 70�- - - � � TRUNK PERMIT NO. ROAD PERM/"f NO. + �'I
i P
PRIVATE DISPOSAL sYFsTEM @ $3.00
— -- —_ —.
ON NECT ADD TiONA�BLDG JR - ARFiDAV.Y 'rYntY as sa3€MEtiT RECORD. INSTR.NO DATE
WORK TO
HOUSE SEWER.._. _ $3.00
O'✓ERK:_OW SEEPAGEPIT.DRAINFIELD
s !
EY N.,CESSPOOL,DRYWELL.MANH OLE @ $5.00 - - -
HWY,OR ST.WIDENING
-- ALTE REPAIR OR ABANDON HOUSE •`
SEW OR DISPOSAL SY TEM $3.00
..._. STATE ENCROACHMENT
PERMIT NO �p
INDUSTRIAL._- - -----3-_ -_ •ylJ .?ted
w WASTE APPROVAL ' a.;_ ✓
CHARGES
LA�H
WNERS PERMIT _
__...____.-__.. ___- CONNECTION CHARGE FEE
THORIZATION TOTAL FEE
REIMBURSEMENT FEE
VE A'r �CH:S DATE A GON'fRACT W17H THE HEREIN NAMED CON- -TOR TO CONNECT THE ABOVE' DESCRIBED EXISTING DWELLING --___ _/y-�y ___F__.r.-.--('. _-_T .__-HE PUBS./ SEWER. APPROVALS CATS INSPECTOR'S SIGNATURE
NEO 7"H[S__�.DAY OF__ --- Z -- __.-R OR NEW HOUSE SEWER'ER.a AG.C.NT . CONNECT ADDITIONALBVILDING OR WORK
RE - --- ----- _-- SEPTIC TANK,SEEP.PIT{S)HFRESY AL.MtlOWLFD�.E THAT 1 HAVE. READ 7HfS APPUCATtON q,ypj"OR 4RAINF'IELD
STATE THAT THE ABOVE: IS CORRECT AND AGRE'C 'f0 COMPLY:LL %OC NTY ORDINANCES AND STATE LAWS REGULATING CESSPOOL (] DRYWELL I] IM6IN(. AND ENIER'�.HEREBY C RTIFY THAT i AM PROPERLY REGISTERED AND/OR ALTER REPAIR,SEWER ORNSED AS REQUIRED BY L_OS ANGLES COUNTY A.ND STATE OF S SWAGE.DISPOSAL SYSTEM
: OidNiA OR THAT 1 AM 7HE LEGAL OWNER OF, AND INTEND 'T O' SCON!'J 7 PL G AND- -____.-DE IN. THE. ABOVE DESCRIBED RESIDENTIAL PROPERTY. ABANDON HLI_ISE SEWERATURE" PERMITTEE• _ �Xk� BACKFILL SEPTIC TANKS
SEES',PIT(S) LJ CESSPOOLS' � I.
'--'--,VALIDATION ROBERT A. WOOD
t' SUPERVISING MECHANICAL ENGINEER
CK.� M:O. CASH
,r
'. 9 6 AUG 4 11 0 2 5 L Q
Xf