HomeMy Public PortalAbout4817 AGNES AVE_Sewer_11/16/1962_sewer connection 81
76A64261
APPLICATION FOR PERMIT
6A842
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING f
1OHN A LAMBM County Eaqq��aeer ADDRESS
WILLIAM A IENSEN Sup t of Bxc%g LOCALITY /
NEARES
FOR APPLIC TO FILL IN CROSS
LEGAL OWNER
DESCRIPTION LOT NO
BLOCK TRACT MAIL
ADDRESS
NO OF BLOCS
SIZE OF LOT NO LOT CITY TEL NO
USE OF DISTRICT NO GROUP MAP PROCESSED BY
BUILDINGS
BK P6 r
CONTRACTOR
:::&� r-,6 ADDRESS / CONNECTION DATA
CITY TEL NO STATION DEPTH
STATE
REGISTRATION NO a S COUNTY MANHOLE REFERENCE UP3
N DESCRIPTION OF _ FEE
PUBLIC SEWECONNECTING TO @ $3 00
SEPTIC TANK SEEPAGE PIT OR Y TYPE OF CONNECTION
P L Y L TTPLOHOM J
PITS AND/OR DRAINFIELD @ S8 00
OVERFLOW SEEPAGE PIT DRAINFIELD }
EXTN CESSPOOL DRYWELL 5
2 00 Ct
HOUSE SEWER CONNECTING TO P C NO O
PRIVATE DISPOSAL SYSTEM @ $100 CO IMP NO JOB NO U
WORK TOTHOUSEISEWER LDG OR Sl 00 TRUNK PERMIT NO ROAD PERMIT NO O
SEWER OR DISPOSAL SYSTEM HOUSE @ $
1 00 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL y
` CHARGES Z
OWNER S PERMIT $ 2 00 CONNECTION CHARGE FEE 6 P d4r.6
AUTHORIZATION riZTAL FEE l REIMBURSEMENT FEE rep-- I�1*4/N J
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON
TRACTOR TO CONNECT THE ABOVE DESCRIBED UIST NG DWELLING APPROVALS DATE INSPECTOR S Sl NATURE
TO THE PUBLIC SEWER
SIGNED THIS 19— NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADDRESS SEPTIC TANK SEEP PITS)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT L HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOLDRYWELL
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWER OR
PLUMBING A D §FAVERS SEWAGE DISPOSAL SYSTE
1 HEREBT/cauty THAT 1 AN PROPERLY REG ERED AND/OR DISCONNECT PLUG AND
L CENSED/A§fRE4UIRED BY LOS ANGEJZS COUNT AND STATE OF ABANDON HOUSE SEWER
CALIFORffAfOlV THAT 1 AM THE L 0 N OF THE ABOVE BACKFILL SEPTIC TANKS [3DESCRVRR
R �NTIALPROPERJ
SEEP PITS ❑ CESSPOOLS
SIGNA13
OF P
VAUDATIOROBERT A WOOD
CL r o Lim SUPERVISING MECHANICAL INGINEER
7 5 y 5 � - t,
C