HomeMy Public PortalAbout9521 LOWER AZUSA RD_Sewer__ DEFAWl%lEN'i' OF COUNW ENGINEER SEWER-SEWAGE DISPOSAL 1
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUP= OF LOS ANGELES gU1LDING
WILLIAM J. FOX, COUNTY ENGINEER I ADDRESS S_,!SgL ` I, Y-
FOR APPLICANT TO FILL IN LOCALITY----7=
BUILDINGf�, NEAREST
ADDRESS ,, f pjJL ws/ CROSS ST. C d
LOCALITY az
41/11 DISTRICT NO. SERIAL NO; PERMIT NO.
NEAREST �; g -
CROSSST. RECEIVED BY Ready for Inspection DATE ISSUED
OWNER
ADDRESS �'�a�� , DQA.�Q USE Z E OCCUPANCY BK MAP PG
CITY *EL.NO.
CONTRACTOR � � � CO.IMP.NO. t Ar Z
ADDRESS Q A.9 JOB NO.
CITY �^ �. TEL.NO..0,6, 4 TRUNK PERMIT NO.
❑�STATE
REGISTRATION NO. �1 `?�+. �o V,� E=-DUN.'- ROAD PERMIT NO. aSI'S'-1 Cj2
LEGAL STATE ENCROACHMENT
DESCRIPTION LOT NO. PERMIT NO.
BLOCK TRACT WASTE APPROVAL
SIZE OF LOTNO OF�v0 NOW ON LOTB� CHARGES
USE OF .ems`
BUILDINGS .�fJj CONNEG% CHARGE FEE
NO. -DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO REIMBURSEMENT F
PUBLIC SEWER @ $ 3.50 L RECEIPT NO. ATE I BY
.HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.OR EXCEPTION RECORD
,•.; WORK TO HOUSE SEWER 1.00
ALTER OR REPAIR EXISTING NO. I DATE I B
SEWER OR DISPOSAL SYSTEM 1.00
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1.00 CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD• 2.00 STATION t DEPTH
CESSPOOL-D RYW ELL
SPECIAL CONDITIONS ONLY 2.00 .. H RE
+ •1 • ANFERENCE LOWER
TYPE OF P-NNE_CTION LENGTH FROM
OWNERS PERMIT ; 1 00 -v* M.L.TO P.L. 1f 3
AUTHORIZATION TOTAL FEE
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING
DWELLING TO THE BSEWEAPPROVALS INSPECTOR'S SIGNATURE DATE
L�,Q R6� n w ,
SIGNED THIS AAY OF_. s=� _19`` NEW HOUSE SEWER
OWNER OR Q ^ 9' ��/fes/ CONNECT ADDITIONAL
OWNERS AGEN ,,...LLL,`��. ..._._/•fir 3�-'�_L!�_Y 111LDING OR WORK
ADDRESS_. _ 1.. .._(,Jd .�_. PTIC TANK,BEEP.PIT(8)
-• r ---- t= ND/OR GRAINFIELD
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLI. aESSPOOL� 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
1 HEREBY CERTIFY THAT 1 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. BACKFILLSEPTICTANKS� c
SEEP.PIT(S)o CESSPOOLS[fir J o G
SIGNATURE '
OF PERMITTEE. L �°d� !f��•
76A642A 663 7/53