HomeMy Public PortalAbout9913 LOWER AZUSA RD_Sewer__ 7
ae-60 1APPLICATION FOR PERMIT 1
E-603 11.55
OF BUMI)ING AND SAFETY SEWER-SEWAGE DISPOSAL
Department of County Engineer
County of Los Angeles TADDRDING
JOHN A LAMBIE,COUNTY ENGINEER ESSCASSATT D GRIFFIN SUP T OF BUILDING ALITY
FOR APPLICANT TO FILL IN SS
NEAREST i
LEGAL `
DESCRIPTION LOT NO 4 OWNER
MAIL
BLOCK TRACTTrADDRESS
NO 07 BLDGS CITYcv
TEL NO
SIZE OF LOT NOW ON LOT
USE
BUILDINGS BK` DISTRICT NO GROUP I MAP
PG gl
CONTRACTOR
ADDRESS CONNECTION DATA
CITY ` TEL NO
66 STATION Q DEPTH
MANHOLE REFERENCE UP
❑ STATE
REGISTRATION NO J 3—
NO DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO TYPE 0 TION LENGTH FROM
PUBLIC SEWER (q $3 50 O
Y CURB PL M L TOPL
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD ® $300
OVERFLOW SEEPAGE PIT,DRAINFIELD P C NO
EXTN ,CESSPOOL,DRYWELL,MANHOLE Q $200 CO IMP NO JOB NO
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM ® $1 00 TRUNK PERMIT NO ROAD PERMIT NO
CONNECT ADDITIONAL BLDG OR STATE ENCROACHMENT
WORK TO HOUSE SEWER @ $1 00 PERMIT NO
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM CV1 $1 00 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNER'S pERMT 3 00
REIMBURSEMENT FEE
AUTHORIZATION I TOTAL FM
1-4q-e;
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- APPROVALS DATE INSPECTOR S$IGNATU E
TRACTOR TO CONNECT THE ABOVEMD CRIBED EXISTING DWELLING
TO THE PUBLIC S R NEW HOUSE SEWER
SIGNED THI AY OF 19 CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK
OWNERS EN
SEPTIC TANK,SEEP,PITS)
ADD RES AND/OR DRAINFIELD
I HEREB ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
I HEREBY EERTIFf THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR sTHAT I AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDEN L PROP_E Y BACKFILL SEPTIC TANKS❑
SIGNATURE • SEEP PITS)❑ CESSP00
OF PERMITTEE
JOHN A LAMBIE.COUNTY ENGINE VALIDATION ROBERT A WOOD,CHIEF PLBG INSPECTOR
34 7 9"
' 4 S SEP 1510 A 550 N