HomeMy Public PortalAbout9546 LOWER AZUSA RD_Sewer__ 24650 INSERT
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76APPLICATION FOR PERM T
642D SEWER—SEWAGE DISPOSAL 1
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER
BUMDING AND SAFETY DIVISION BUILDING
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NEAREST
FOR APPLICANT TO FILL IN CROSS ST
LEGALro
/
DESCRIPTION LOT N OWNER /
BLOCK TRACTMAIL
ADDRESS
No OFBLDGS
SIZE OF LOT NOW ON LOT CITY TEL NO
USE OF / DISTRICT NO GROU MAP PROC S BY
BUILDINGS
/A A
-moi �, v - "
CONTRACTOR ��
ADDRESS CONNECTION DATA
CITY TEL NO I STATION o. DEPTH
STATE MANHOLE REFERENCE
REGISTRATION410 COUNTY LOWER
No I DESCRIPTION OF WORK fEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3 00 TYPE OF ION LENGTH FROM
SEPTIC TANK SEEPAGE PIT OR Y CURB P L M L TO P L
ITS AND/OR DRAINFIELD @ $300
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL 32 00
HOUSE SEWER CONNECTING TO P C NO
PRIVATE DISPOSAL SYSTESt 00 CO IMP NO JOB NO p.
CONNECT ADDITIONAL BLDG OR TRUNK PERMIT NO ROAD PERMIT NO
WORK TO HOUSE SEWER 1 00 v
AEWER 0 EPAIR OR ABANDON HOUSE @ Sf 00 STATE ENCROACHMENT {q
SYSTPERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS POUCT 5 2 00 CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRI ED EXISTING DWELLING APPROVALS DATE INSPECTOR S SIGNATURE
TO THE PUBLIC
SIGNED THI AY OF 9 NEW HOUSE SEWER f/
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADDRESS . SEPTIC TANK SEEP PIT(S)
AND/OR DRAINFIELD
I HEREBf ACKNOWLEDGE THAT 1 HA READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGE S OUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR T AM T LE OWNER OF THE ABOVE
DESCRIBED RESIDE A PROPE r SEEPBACKFI LLPiT S ❑SEPTIC CESSPOOLS
TANKS
SIGNATURE
OF PERMITTE
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AL0 ROBERT A WOOD
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CCARR SUPERVISING MECHANICAL SN6INfiER
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