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USE808 11-57 APPLICATION FOR PER AT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUIL
AD.
C�Olr AjLAMBIE, County Engineer
A S TT
GRIFFIN, Sup t of Building LOCALITY I ITY T'lem-d'e 01-:�-'7
NEAREST -r
t r--et
0
FOR APPLICANT TO FILL IN CROSS ST. LJIVP� U�Un-
LEGAL len Cohstruc'.�ion �;o.
�s-a _g c)a
'0'
DESCRIPTION LOT NO. ? 111111E�'
BLOCK TRACT24"9 MAIL
f ADDRESS 10229 Azusa Road
_' 1 1. 3 )l
NOOF BLDGS.
SIZE OF LOT NOW ON LOT CITY 131 TEL,N0: Gi. 35914
USE OF
BUILDINGS R'_'Sid'-ellt DISTRICT NO, GROUP i MAP
PC;
CONTRACTOR L�, 1), n
Con,structic
ADDRESS FSG X 08 rnwNre"TION DATA
;��'P
CITY 51024
TEL.NO. Ed. 83024 STATION DEPTH
STATE MANHOLE REFERENCE
REGISTRATION NO. 1136-13 El COUNTY
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER X=XK 00 TYPE OF CONNECTIQLENGTH FROM
YCURB M,L.TO P.L.SEPTIC TANK,SEEPAGE.PIT OR 0c) L.,
E�TSAND/OR DRAINFIELD _ @ $3.00 Y. —
OVERFLOW SEEPAGE PIT,DRAINFIELD
EX N_CESSPOOL,DRYWELL,MA.NHOLE @ $2.00
HOUSE SEWER CONNECTING TO P.C.NO
t PRIVATE DISPOSAL SYSTEM @ $1.00 CO, IMP,NO. JOB NO..
CONNECT XD_D_IT_lONCBLDT_6R____ �''L
WORK TO HOUSE SEWER @ TRUNK PERMIT NO, ROAD PERMIT NO.
ALTER,REPAIR OR ABANDON HO—USE
EWER OR DISPOSAL SYSTEM @ $1.00 I STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL CHARGES
OVVNER'S PERMIT 00 CONNECTION CHARGE FEE
AUTHORIZATION T )TAL FEE REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXfsTfNGDWELLING APPROVALS I DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS---DAY OF NEW HOUSE SEWER
OWNER OR s CONNECT ADDITIONAL
OWNERS AGENT—l"WN BUILDING OR WORK
ADDRESS-- SEPTIC TANK,SEEP,PITS)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY CESSPOOL 0 DRYWELL 0
WITH ALL COUNTY ORDINANCE'S AND STATE LAWS REGULATING
PLUMBING AND SEWERS. ALTER,REPAIR,SEWER OR
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR __SEWAGE DISPOSAL SYSTEM
LICENSED AS REQUIRED BY LOS Ak- GEtV COUNTY AND STATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT I AM TH.E-_LEA L OWNER OF THE ABOVE ABANR2,N HOUSE.SEWER
DESCRIBED RESID
,:E
BACKFILL SEPTIC TANKS Cl
SIGNATURE
SEEP. PIT(S) 0 CESSPOOLS 0
OF PERMITTEE
VALIDATION ROBERT A. WOOD
CK. M.01 CASH SUPERVISING MECHANICAL ENGINEER