HomeMy Public PortalAbout9860-9880 LOWER AZUSA RD_Sewer__ 76A 642D-CE808-10-71 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION F.S
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a w a? Z U S Ir} 0
M N �
FOR APPLICANT TO FILL IN eb uj l K D
LEGAL Q
DESCRIPTION LOT NO. A/C.C� OWNER 15 E �� e . u r "
MAIL ,L i Row 1 K
BLOCK TRACT /l+ ADDRESS T� /ter //��
NO. OF
SIZE OF LOT IU S NOW ON LOTS CITY L />/JI� TEL. NO. p[ g
USE OF
DISTRICT NO. GROUP MAP OCESSED BY
BUILDINGS Alb PS
CONTRACTOR AuCila
SEtr, � IZ 5EJZVIC �� f3 - /L
ADDRESS Q 5J'4, P E �'l7: CONNECTIO DATA
CITY G m /e-////�/y��AAc l TEL. NO. #Va- ZSV LIC I STATION DEPTH
STATE /V q ! ! GLASS '�T� MANHOLE REFERENCE UPPER
LICENSE NO.. D I • LOWER
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO -� Y. CURB P.L. M.L.TO P.L.
PUBLIC SEWER ! $7.00
SEPTIC TANK,SEEPAGE PIT OR P.C.NO.
PITS AND/OR DRAINFIELD $10.00 CO.IMP. NO. JOB NO.
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO, ROAD PERMIT NO, 0-
PRIVATE DISPOSAL SYSTEM ® S3,00 0
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVEE EAS[xExt RECORD.INSTR.NO. DATE 0
WORK TO HOUSE SEWER $3.00
OVERFLOW SEEPAGE PIT.DRAINFIELD oC
EXTN..CESSPOOL,DRYWELL. $5.00 HWY.OR STWIDENING O
. .
ALTER.REPAIR OR ABANDON HOUSE I"-
SEWER OR DISPOSAL SYSTEM $3.00 STATE ENCROACHMENT W
MANHOLE O $7.00 PERMIT NO. a
INDUSTRIAL
WASTE APPRO
OWNERS PERMIT E 3 00 HARGES
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE '�"'
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NA ED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEP `fI I MATE P T R' SIGN TU E
SIGNED THIS DAY OF G_ ,� 19
OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK T
SEPTIC TANK.SEEP,PIS)
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL [I
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR.SEWER OR
LICENSED AS REOUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL WNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABOVE D SCRIBED E DENTI PROPERTY ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMffTEE SEEP,PITS) El CESSPOOLS ❑
VALIDATION CK. M.O. CASH
r
28 AIS 9zu A 10.00
F
76A 6420 -CE808-10-71 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BU DIN
y0�
ADDRESS
T
NEARE
NEAREST 'Qy
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL /
DESCRIPTION LOT NO. :;;t— OWN -
MAIL 171 C'tlt"
BLOCK TRACT , M• ADDRESS t
NO. OF BLDGS. r7
SIZE SOF LOT NOW ON LOT CITY TEL. NO. p,[
USE OF t
BUILDINGS DISTRICTNO. GROUP��B
�MAP PROCESSED BY
/60NTRACTOR
ADDRESS CONNECTION ATA
STATION DEPTH
CITY TEL. NO.
STATE LIC MANHOLE REFERENCE UPPER
LICENSE NO, CLASS LOWER
NO. -DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L.
PUBLIC SEWER ! $7.00
P.G.NO.
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 510.00 CO.IMP.NO. JOB NO.
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 53.00 TRUNK PERMIT NO. ROAD PERMIT NO. a O
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT w�lv[R [�s[r[xi RECORD.INSTR.NO. DATE 0
WORK TO HOUSE SEWER $3.00
OVERFLOW SEEPAGE PIT.DRAINFIELD Of
EXTN..CESSPOOL.DRYWELL. 0 •5.00 O
ALTER.REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING
SEWER OR DISPOSAL SYSTEM ! $3.00 STATE ENCROACHMENT W
MANHOLE O $7.00 PERMIT NO. p.
INDUSTRIAL h
WASTE APPROVAL Z
OWNER'S 3 00 CHARGES
PERMIT S CONNECTION CHARGE FEE ®®
AUTHORIZATION TOTAL FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLICSEW R. APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS AY F �r_� c- 197Y
OWNER OR w NEW HOUSE SEWER
OWNERS AGENT
CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
SEPTIC TANK.SEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING I�
PLUMBING AND SEWERS. CESSPOOL [IDRYW ELL ❑
I HEREBY CERTIFY THAT AM ROPERLY REGISTERED AN OR ALTER,REPAIR,SEWER OR
LICENSED AS REOUIREDBY LO A L S CO T AND T E OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THATAM LE A N AND END TO DISCONNECT PLUG AND
RESIDE IN, THE ABO CRIB D PRO Y. ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMITTEE ❑
SEEP.PI7(5) Cl CESSPOOLS
VALIDATION CK, M.O. CASH
2.0 ; 3 81 A 6 0 OD 0