HomeMy Public PortalAbout9428 LOWER AZUSA RD_Sewer__ DEPARTMENT OF COUNTY ENGINEER SEWER—SEWAGE DISPOSAL
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF I.OS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER BUILDING
ADDRESS
FOR APPLICANT TO FILL IN LOCALITY
BUILDING =INEAREST
ADDRESS &E sg ¢ 't >^ CROSS ST.
LOCALITY DISTRICT NO. SERIAL NO. PERMIT NO.
NEAREST 3 /r J � ( A 0 7 s
CROSS ST. 4°�-
RECEIVED BY Ready for Inspection DATE ISSUED
OWNER 6
MAIL ' ��,
ADDRESS - tea_„� ,f ! SE IO OCCUPANCY BK MAP PG
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CIT T
CONTRACTOR CO.IMP.NO. G/
ADDRESS
JOB.NO.
CITY TELAO. TRUNK PERMIT NO.
STATE
REGISTRATION NO. COUNTY ROAD PERMIT NO.
LEGAL �+
DESCRIPTION LOT NO. STATE ENCROACHMENT
PERMIT NO.
BLOCK TRACT `/ INDUSTRIAL
WASTE APPROVAL
SIZE OF LOT7,0, N0.OF BLOCS.
'i NOW ON LOT / CHARGES
USE OF ,�
BUILDINGS CONNECTION CHARGE FEE
NO. DESCRIPTION OF WORK FEE REIMBURSEMENT FEE
HOUSE SEWER CONNECTING TO
-
{ PUBLIC SEWER Q S 3.50 RECEIPT NO. DATE BY
(–
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.OR EXCEPTION RECORDED
WORK TO HOUSE SEWER 1.00
ALTER OR REPAIR EXISTING NO- DATE. BY
SEWER OR DISPOSAL SYSTEM L00 -u-
DISCONNECT AND ABANDON SEWER CONNECTION DATA
AND/OR DISPOSAL SYSTEM 1.00 C
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAtNFiELD 2.00 STATION DEPTH
CESSPOOL—ORYW ELL
SPECIAL CONDITIONS ONLY 2.00I MANHOLE REFERE
tUPPER
mywrR-
TYPE OF CONNECTION LENGTH FROM
CURB _J_ M.L.TO P.L. —
OWNERS PERMET ; � I 00
AUTHORIZATION I TOTAL FEE * I ( /'`,��� —
1 HAVE THIS DATE CONTRACTED WITH THE HERE ""NAMED
HAVE
TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER
SIGNED THIS_ PAY.OF. --._.._ s9;;;� NEW HOUSE SEWER
x CONNECT ADDITIONAL
OWNER R
OWNERS AGENT. r _�_ _ BUILDING OR WORK
ADDRESSI.7t'2._. _.. SEPTIC TANK,SEEP.PITS)
�: _. _ AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE.THAT 1 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
I 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 E]
SIGNATURE SEEP.PIT(S)E] CESSPOOLS 0
OFPERMITTEE.--------------------•------------------------------------------.:.:.-------
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