HomeMy Public PortalAbout9509 LOWER AZUSA RD_Sewer__ F80� 2;7a APPLICATION FOR PERMIT
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COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER'
BUILDING AND SAFETY DIVISION FN-EAREST
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JOHN A. LAMBIE. COUNTY ENGINEER f lr r d a F /
21
COLEMAN W. JENKINS, SUPT. OF BUILDING y
O APPLICANT TO FILL IN T.
(PRINT OR TYPE ONLY)
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LEGAL
DESCRi 710N LOT NO OWNER
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MAIL y
BLOCK _.-,RACT k ADDRESS y _
,A NO. OF SLOGS.
SIZE OF LOT .R NOW ON LOT CITY TEL. NO.
USE OF
BUILDINGS 015TRICT NO. GROUP CLASS "AAP .PROCESSED ICY
BK Pa
G.ONTRACTOC.." I� }_
ADDRESS d CONNECTION DATX
CITY ..�. TEt NO. +� '.' .-„. �.;;: STATION ;� .,,f. DEPTH
STATE ,. LIC - , MANHOLE REFERENCEY1PPER-
�._ ,...LOWER
LICENSE NO: _3 ✓ ..D`' r _-_ CLASS L� f� ...
NO. -DESCRIPTION OF WORK FEE_ _ _ TYPE OF C,Q,i�}N$ TIOM LENGTH FROM J
i HOUSE SEWER CONNECTING TO p Y. (CURB P.L. M,[_ TO P.L. j _-
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PUBLIC SEWER � S-5-.00 P.C.NO -
SEPTIC TANK. FEPAGE PIT DR !� JOB NO.
PIT AND'OR DRA NFIELD $10.00 CO.IMP.NO.
HOUSE SEWER CONN E(_TI NG TO.--- —. --.__ —_ —_ - PERMIT
TRUNK PERMIT NO ROAD PERMl7 NO.v..
PRIVATE DISPOSAL SYSTEM � $3.00 � � ! Le
CONNCT ADDLITIONABLDGOR AFFIDAVIT wAtYER Ek SE MFkF J RECORD. IN57R NO
EDATE `J
WORK TO HOUSE SEWER 'C+>p $3.00 (,
OVERFLOW SEEPAGE—PIT,DRAIN FIELD
EXT N..CE5SPOOL.DRYW ELL.MANHOLE* E5.00 �
._1__—�_ HWY.OR ST.WIDENING 0
ALTER.REPAIR OR ABANDON HOUSE f
SEWER OR DISPOSAL SYSTEM E3.00 STATE ENCROACHMENT
— PERMIT NO _ Duj
.,
INDUSTRiAL (CS
1 WASTE APPROVAL
CHARGES
i T�.OW�NTE�R'S PERMIT ------ � `` Oo. ---- --- ----
1H0[{i ATION TOTAL FEE Ca?NNECTION CHARGE EEE
A
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMSURSEMEN7 FEE
TRACTOR TJ CCNN ECT THE ABOVE DESCRIBED EXISTING DWELLING - n �y E '-*��-+--�-' ----
TO THE PUBLIC 5E'W ER, APPROVALS— ii DA ,INSP TOR'S SIGNATURE
S!GN ED TH i S.__.DAY OF S 9— ----- ---- -�---'---- _ ---
OWNER OR NEW HOUSE SEWER
OWNERS AGENT---
CONNECT AOQITIONAL 'I i
BUILDING OR WORK
ADDRESS--------_ _ _ K,SE —
- — SEPTIC TANK,SEEP,P1T(5)
HERESY ACKNOWLEDGE THAT I HAVE READDTTHIS APPLICATION 1
AND!0H DRAIfvFiELD
'NO
ST ATE. THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY —.— —.----- — ---
WITHAL.L COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMB:NG AND SEWERS- CESSPOOL ❑ DRYWELL �J -
1 HF_REBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER.REPAIR.,SEWER OR
L.CENS ED AS REOUI7
6f BY LO%'_.f NGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM 1
CALIFORNIA OR THAT IMAM THE LE(�ssA�L OWNER OF, AND INTEND TO
`T” DISCONNECT PLUG AND
RESIDE IN, THE `r
AB] E D SCR IBED'RESIDENIIAL PROPERTY.
�,. :. ABANDON HOUSE SEWER
SIGNATURE'. �e /�,;� a + BACKFILL SEPTIC TANKS L-1
OF PERMTTTEEz ' ¢ltn.� 4� SEEP.PET IS) ❑ CESSPOOLS �I i
VALIDATION JACK R. ALLEN
SUPERVISING MECHANICAL ENGINEER
CK. M.0. CASH
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