HomeMy Public PortalAbout9419 LOWER AZUSA RD_Sewer__ -E.608
'8A6420 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL �
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION F".
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j IiN A. LAMBIE, County Engineer C --- -
WILLIAM A. JENSEN, Supt of Building spa
YFSR APPLICANT TOTI.L I1�6sr -- - - _
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_.-LEGAL__._
OESCR rION LOT N L 1✓�- y At i�+ '+ OWNER __ .•• �.- �� _._._ _ ___
MAIL
BLOCK TRACT ' - tj ADDRESS
NO. OF ESLD GS.__
SIZE C._ I_O'T NOW ON LOT CITY TEL. NO.
USE O
B I L 0,N GS "�.,y „ DIS7RiGY 116. GROUP MAP PROCESSED BY
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CONT ACCTO_R - .• P +' ..
ADEss _ CONNLCTIOhi DATA s
TEL - -.'°..'-'tee STATION DEPTH
"S N � � T
UfIrE
.R
REGI TRcTION NO OUNTY MANHOLE REFERENCE
NG. i DESCRIPTION OF WORK, F`E _ _ � ,y7YPFr OF cnMNE.C7tQN LENGFROM.
_. .. _ Q�
,j HrJJ L SEWER ER CONN4 CTf P1a TfJ CURB P,L _._M.L TO P
J/ P JBI_I.. S W FR @ SS00
_ .. . �-r --- P.C.NO,
SE Tip^, -rNY SEEPAGE PIT OR
CO,.MP NO- ,� -` JOB NO
ITS ANDi Oh,1 P7AINFIELD � $10.00 __.
HOUSE SEWER(-,ONNE.G,T NG TO I TRUNK PERMIT NO. ROAD FERMlT NO.� ,/ �� ^`f •'
PRIVATE:DISPOSAL 5Y TFM _� $-,OK: I -_. ___.- .._ S-`<-.�1---E�
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CNNEC'Y A D ifj dA SLOG-OR t gFFiUAVIT WA?Yea r FA5fF1ENT R€CORD,I7J STK.NO: i DATE,
WORK TO YO U.E SEWER @ $3.00 i
uVFREL.OW SC'-PA(aP PiT URA NFfC..D
€AT f S OGL.DftYW ELL,tAANHOLE @ $ .00 I I
_. _--_ _____-
HVJY.OR 5 T.WIDENING
I Al FR REPAIR OR AHA N,.,ON HOLSE
S \v E:H OF,., SP C:AL SYSTEM STATE ENCROACHMENT
{ PERMIT NO
INDUSTRIAL,
+ I WASTE APPROVAL
CHARGES
OWNDIL`S PERMIT $! 2, 06 — --- — — — — — — -----
COFJ'tJEC.CION CHARGE.FEE.
AUTHORIZATION TOTAL FEE yrp
REIMBURSEMENT FEE
HAl AT THIS DATE A CONTRACT WITH 'HE HEREIN NAMED CON- ---- ---- - �.%
RAS 6R t0 Cq VNF'.'Y :HE ABC) U.ESCie BEU EXISTING U'Wf'..LING
YGH "I'NC Y�J'J'LC ...EWER DATE 1.11$1 Y;L°Y'PS SIGNATURE
APPROVALS –
SIGNED THIS--DAY Or --
r
OWNER OF NEW HOUSE SEWER
OWNERS AGE.Nr _ --_--.__ CONNECT ADDITIONAL
—.-.
BUILDING OR WORK
EPTiC TANK.
1 N.fxCPSY ACt'NOWLEDGE THAT I HAVE RF_AU THIS APPLICATION AND/OR DR.AINFt ELD � I
AN:r3 TATE;. THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUN17Y ORDINANCES AND STATE ;_AWS REGULATING
PLUM131NG AND SEWERS. CESSPOOL ❑ ORIWELL '
1.7 REB, CER'T�F' H 7' 1 AM PROPERLY REGISTERED AND�OR ALTER;REPAIR,SEWER OR -��_---- --
I =E:NS{-D A.S: NE 1RE BY LOS APV G.L F.S C'OUhITY A'VU STATE LIP SEWAGEDISPOSAL SYSTEM
GALIF RNIA OR HAT AM THE LEGAL O R GF AN_ INTEND 'TC
DISCONNECT' PLUG A`•i
RESICF IN, AB E DESCRIBED R£. 'TIP. 'PR R'T7' ABANDON HOUSE SEWER 'I
SIGNATURE _ y.+a e. ,
OF PRM F dr`+�•• IIA KFi 5 PTIC TANKS �
---_— _ __.__ _._— _._—____ SEEP.'PIT(5) .-_...v POOLS �1
VALIDATION..- (ROBERT A. WOOD
SUPERVISING MECHANICAL VJGINEER
CK. M.O. !GASH
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