HomeMy Public PortalAbout9965 LOWER AZUSA RD_Sewer__ 76A 642D•-.CE80S,-b/73 ' APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION A 10 F.R. If U
C
FOR APPLICANT TO FILL IN
LEGAL
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DESCRIPTION LOT NO IV J OWNER
p MAIL
BLOCK , TRACT p2-VO ADDRESS
NO OF SLOGS
SIZE OF LOT NOW ON LOT Q CITY TEL NO
USE OF ' DISTRICT NO GROUP MAP PROCESSED BY
BUILDINGS BX PS
CONTRACTOR ✓-�v ,�
ADDRESS CONNECTION DATA
J l
CITY VITEL NO 'L�,� STATION 3+34
DEPTH
STATE LICENSE NOS LIC / MANHOLE REFERENCE 3+00
" UPPER
AQUGLASS (''� +Q D - KLowe
NO DES RIMON OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTI NO TO Y CURBP L M L TOP L
PUBLIC SEWER ® $7 00 D PC NO
SEPTIC TANK SEEPAGE PIT OR
PITS AND/OR DRAINFIELD ® 81000
CO IMP NO JOB NO
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO
PRIVATE DISPOSAL SYSTEM $300
CONNECT ADDITIONAL BLDG OR AFFIDAWifj_;iWj SAsiRIINT RECORD INSTR NO DATE
WORK TO HOUSE SEWER ® $300
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL is $S 00 HWY OR ST WIDENING
ALTER REPAIR OR ABANDON HOUSE C
SEWER OR DISPOSAL SYSTEM $3 00 STATE ENCROACHMENT FP
MANHOLE ! $7 00 PERMIT NO W
INDUSTRIAL h
WASTE APPROVAL c.
m
owws s A� CHARGES
YYiaaLl W CONNECTION CHARGE F!!
AUTHORIZATION I TOTAL FEE OV
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING AOVAL�
TO THE PUBLIC SEWER DATE INSPECTAR 8 SIGNATURE
SIGNED THIS DAY OF 19_ +�
OWNER OR NEW HOUSE SEWER
OWNERS AGENT
CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
I
HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION SEPTIC TANK SEEP PIT(8)
AND STATE THAT THE ABOVE IB CORRECT AND AGREE TO COMPLY AND/OR DRAINFIELD
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
1 HEREBY CERTIFY THAT 1 AM PROPERLY GISTERED AND/OR ALTER REPAIR SEWER OR
LICENSED AS REQUIRED BY LOS ANG S C NTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT M THE LEO W OF AND INTEND TO DISCONNECT PLUG AND
RESIDE IN THE ABOV ESCRIBE R ID TIAL PROPERTY ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS [3OFF PEN PSBMITTEE 8EEP PIT(8) ❑ CEBSPOOL6
VALIDATION M O CASH
WORKERS COMPENSATION
4 8 8;!JUL 6 8 0 18 10
'OLICY NUMBER: j yo- f