HomeMy Public PortalAbout9508 LOWER AZUSA RD_Sewer__ TINPLE CITY
:E8APPLICATION FOR PERMIT '
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COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL -'
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS C (�j t �(}wer Azusa Rd.
COLEMAN W. JENKINS, SUPT. OF BUILDING
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST. Tempie City Blvd,
LEGAL i
O ESCRIP710N _ LOT NO. y _ - - OWNER -.._�n 6 w yY Cs
---____ a- �C ii 6t
BLOCK TRACT 4 MAIL /�y.er Azusa
... t"����-- ADDRESS 9508 E. I!V YYVi Af�66Y�S Rd♦
-- �— N0. OF BLDGS-- _� -- —
SIZE OF LOT _ NOW ON.LOT CITY I p Pj t,V TEL. NO,
USE OF
BUILDING (1 DISTRICT NO. GROUP MAP PROCESSED BY
BK IG
CONTRACTOR �t�}��ams q�y�-� �t��,., h ✓:�,
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ADDRESS MaXSon CONNECTION DATA -
TEL. NO. STATION "� (.'. DEPTH
CITY "
l conte —L 44---2 C2® t
- -� ! UPPE. _
L t CE rNSF_ NO,. ,�2 � GLASS 8 LIC MANHOLE REFERENCE F �^"y .��'t1,� „� LOWER
Np. 1 DESCRIPTION OF WORK FEE T, _
_ _ TYPE O TION WIL.TO
FROM
HOUSE SEWER CONNECTING TO 1� Y. CURB p.L. M.L TO P.L.
PUBLIC SEWER .__Q $5.00 '.� --.. P C--NO PS
iSEPTIC TANK.SEEPAGE PIS OR 0
�- CO.IMP.NO. /j ��, JOB NO.
i PITS ANDi OR DRAINFIELD @ $10.00 -----___ `.
____. _ _._._.--._.. __T-___ _..
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.tK
PRIVATE DISPOSAL SYSTEM $3.00l�' =�
-- __ _ _ -- -- __-_ - O
CONNECT ADD17{ONAL BLDG OR AFFIDAVIT wafYERl EaSEME NT RECORD,INSTR,NO. DATE �
WORK TO HOUSE SEWER @ $3.00 -
TONERE LOW SF.EFAGE PIT.DRAINFIELD j--
!EXTN..CESSPOOL.ORYWELL.MANHOLE @ $S.00 O-
ALTER.REPAIR OR ABANDON HOUSE - HWY,OR ST.WIDENING- tn
SEWER OR DISPOSAL SYSTEM $3.00 ! STATE ENCROACHMENT
I j PERMIT NO.
------ INDUSTRIAL
WASTE APPROVAL
— _-
OWNER7S PERMIT _$�_ 2 00 — - CHARGES
AUTHORIZATION TOTAL FEE1 CONNECTION N CHARGE FEE -^ ---- --
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING -- -- - -
TO THE PUBLIC SEWER. APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS_ DAY OF__ 19._ ---------`---- — - --
OWNER OR NEW HOUSE SEWER' ,°1t
: '-
df
OWNERS AGENT-
CONNECT '-
CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
----------- ---- -- --__ ----- SEPTIC TANK,SEEP,PITS)
I HFRURY ACKNOWLEDGE THAT i HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABDVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL Cl ORYWELL ❑
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR p } T
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEMI dfr,
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF'AND INTEND TO -------- -_-- a„ —
DISCONNECT PLUG AND
RESIDE IN, THE ABOVE DE, BED RESIDENTIAL ROP TY. t �v
ABANDON HOUSE SEW ER t
SIGNATLI RE __ _ __ - / -- ❑_
OF. PERMTTTE SACKFILLSEPTIC TANKS (F +nI
SEEP,PIT(S) ❑ CESSPOOLS ❑ • �t�
VALIDATION JACK R. ALLEN
SUPERVISING MECHANICAL ENGINEER
M.O. CASH
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