HomeMy Public PortalAbout9551 LOWER AZUSA RD_Sewer__ /7
5-65
76A645-65
APPLICATION FOR PERMIT
76A 64
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A LAMBIE, County Engineer ADDRESS
COLEMAN IN JENKINS,Sup't of Building
LOCALITY
NEARE
CROSSSST �` S .
IN EAR
FOR APPLICANT TO FILL IN
LEGAL
DESCRIPTION LOT NO V OWNER
MAIL
BLOCK TRACT Z ADDRESS
NO OF BLOGS )
SIZE OF LOT Q NOW ON LOT / CITY TEL N Q
USE OF
BUILDINGS / DISTRICT NO I GROUP MAP PROCESSED BY
BK !'PG
CONTRACTOR Q % g 3
ADDRESS �Yi�� CONNECTION DATA
CITYTEL NO STATION DEPTH ,
LICE SEICE NSE MANHOLE REFERENCE 1 a LO
C
NO LASS -� •
NO DESCRIPTICrN 15F WORK FEE TYPE OF CTION LEND H FROM
HOUSE SEWER CONNECTING TO �` Y R PL ML TOPL,
PUBLIC SEWER C $ 5 00 v -31
/ PC NO a
btrilL AN SEEPAGE ]TOR JOB NO
PITS AND/OR DRAINFIELD C CO IMP NO$10 00 O
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO D V
PRIVATE DISPOSAL SYSTEM C $ 3 00
CONNECT ADDITIONAL BLDG OR AFFIDAVIT I WAIVER EASEMENT RECORD INSTR NO DATE
WORK TO HOUSE SEWER @ $ 3 00 O
J'ALTER RLA HOUSE r
SEWER OR DISPOSAL SYSTEM 6 $ 3 00
HWY OR ST WIDENING a
EXTN CESSPOOL MANHOLE @ $ 5 00 STATE ENCROACHMENT Z
PERCOLATION TEST @ $ 5 O0 PERMIT NO
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT $ 2 00 CHARGES
AUTHORIZATION I TOTAL FEE 2
Q a CONNECTION 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 SEW R APPROVALS DATE I S ECTOR S ATURE
SIGNED THIS DAY OF 1
OWNER OR NEW HOUSE SEWER
OWNERS AGENT
CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION SEPTIC TANK SEEP PIT(S)
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY AND/OR DRAINFIELD
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
1HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF AND INTEND TO DISCONNECT PLUG AND
RESIDE IN THE OVE DES RIBEO�ENTI PROPERTY ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS
T ❑
OF PERMITT SEEP PIS) F-1CESSPOOLS It
VALIDATION
K M O CASH
0 1 8 5-G My26 1 0 7.00- 4
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