HomeMy Public PortalAbout9621 LOWER AZUSA RD_Sewer__ I
24650 INSERTS
786A642°
` A64iDe° APPLICATION FOR PERMIT
S 1
COUNTY OF LOS ANGELES EWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS /
JOHN A. LAMBIE. Couatp En neer
WILLIAM A. JENSEN, Sup'4 of Building LOCALITY
NEAREST C
FOR APPLICANT TO FILL IN CROSS ST.
T
LEGAL
DESCRIPTION LOT NO. OWNER 1 V
BLOCK TRACT 7MAIL
ADDRESS
NO.0 BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USOF
BUE DINGS DISTRICT NO. GROUP MAP PROCESSED#Y
f BK PG f
CONTRACTOR I6. �.,..-(.✓'L•�/ ,
ADDRESS ,L
�1 T�JC. " 9! w - A y 2 6A CONNECTION DATA
CITY �'r�}E�l L f1{i.�1flrK: CALIFORNIAd
STATION DEPTH
STATE MANHOLE REFERENCE 'UPPER
REGISTRATION NO. q Y7 t ; COUNTY LOWER
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3.00 TYPE OF CONNECTION LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR Y. CURB P.L. M.L.TO P.L.
PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT, DRAINFIELD
EXTN..CESSPOOL, DRYWELL @ $2.00 _
HOUSE SEWER CONNECTING TO - P.C.NO.
PRIVATE DISPOSAL SYSTEM @ $1.00 aft CO.IMP. NO. JOB NO.
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT NO. V
-LFWORK TO HOUSE SEWER @ $1.00
SEWER OR PAIRO R ABANDON STEM HOUSE Co) $1 OO STATE ENCROACHMENT
PERMIT NO. MO
INDUSTRIAL U
WASTE APPROVAL W
CHARGES I !i
OWNER'S PERMIT $ 2 00 CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE 5 REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE AREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS DAY OF 19_ NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL [I DRYWELL ❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THA, I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED LOS ANGELES COUNTY AND STATE OF ABANDON CT PLUGHOUSE AND
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER,OF THE ABOVE
WER
DESCRIBED RESIDENT ROP Y BACKFILLPIT SEPTIC
CESSPOOLS
E] ❑
SIGNATURE SEEP.
OF PERMITTE
®r + �VALMATION ROBERT A. WOOD
M.°. CASH SUPERVISING MECHANICAL ENGINEER
- 1-1 S 4,cJ J& 3 1 0 A 5.00N 7
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