HomeMy Public PortalAbout9512 LOWER AZUSA RD_Sewer__ 24650 INSfQTS �9
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7eA6420 APPLICATION FOR PERMIT
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COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL 1
DEPARTMENT OF COUNTY ENGINEER.
BUILDING 3.:4„ "Y
BUILDING AND SAFETY DIVISION ADDRESS 3
a
jOIIN A. LAMBIE. County Engineer
WILLIAM A. JENSEN, Supt of wilding LOCALITY ° r
NEAREST
FOR APPLICANT TO FILL IN cLEGAL
ROss sr.
DESCRIPTION LOT NO. 1 OWNER <
BLOCK TRACT MAIL
�J �« J�
NOADDRES „� >cs.
Ys-
SIZE OF LOT LD-, �J ' W ON LOTS CITY TEL. NO,
USE OF
BUILDINGS k�IZ4-1 c1 d„° DISTRICT NO. GROUPMAP PFPCED BY
81C PESS
G
CONTRACTOR
ADDRESS F < "y CONNECTION DATA
CITY a y TEL,NO. STATION DEPTH
STATE MANHOLE REFERENCE UPPER
REGISTRAT10N NO. Cj COUNTY LOWER
NO. DESCRIPTION OF WORK FEE - ,
HOUSE Sf WFR.CONNECTINGTO
5-2'. �
PUBLIC SEWER @ $3.00
TYPE F CONN CfION LENGTH FROM
SEPTIC TANK SEEPAGE PIT ORY, CURB P.L. M.L.TO P.L.
ITS ANO/OR DRAINFIELD @ 53.00
OVERFLOW SEEPAGE PIT, DRAINFIELD
EX N . CESSPOOL. DRY`A+ELL. @ $2.00
j H RISE SEINER CONN"CT'ING TO
PRIVATE DISPOSAL SYS'CEM @ $1.00 CO.IMP.NO. ^dOB Np:
CONNECT ADDiTiONAL BLDG.OR TRUNK PERMIT NO. AD�PERid:l<T U
N0.
_I WORK TO HOUSE SEWER @ $1.00 RO _
Al-TER,7tEPATR"'OR"'1>i•'B�AI*DON HOUSE _. STATE ENCROACHMENT "` �
SEWER OR--Him P.DSA.L.S-F.s:''M @ S1
.00 PERMIT N0. 0
g.
INDUSTRIAL
WASTE APPROVAL P.
CHARGES ta
OWNER'S PERMIT $ 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE L - REIMBURSEMENT FEE
1 HAVE AT THIS DATE ACONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS I DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS DAY OF 19r NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADDRESS.__ SEPTIC TANK,SEEP.—PIT(S)
— AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT 1HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL [I DRYWELL
W17H ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEVIEPOR
-
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM _
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED ANA/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE' Or ABANDON HOUSE SEWER
CALIFORNIA. OR THAT I AM THE LEGAL OWNER OF T ABOVE
DESCR19ED RESIDENTIA PROPERTY. BACKFILL SEPTIC TANKS ❑
SIGNATURE -' t ✓-.F _ a SEEP. PITS) Q CESSPOOLS
OF PERM.ITTE .f `" � ''� ���
VALIDATION.--_ ROBERT A. WOOD
CK, M.0. r'CASH SUPERVISING MECHANICAL ENGINEER
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