HomeMy Public PortalAbout4839 AGNES AVE_Sewer_6/26/1970 CE81s$ z as APPLICATION FOR PERMIT
76A 642D
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISIONBUILDING
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JOHN A LAMBIE COUNTY ENGINEER ADDRESS �f C1
COLEMAN W JENKINS SUPT OF BUILDING LOCALITY 'fC `e cf"�e
NEAREST Lv ' s u j4
FOR APPLICANT TO FILL IN cRoss BT
L GAL ��w�•
DESCRIPTION LOT NO OWNER
MAIL
BLOCK TRACT 3— ADDRESSe
O /� rte/?/ y.P�F�rw /f
SIZE OF LOT NOW ON B J �
LOT CITY • TEL NO �j / ��
USE OF
BUILDINGS L DISTRICT NO GROUP MAPP. PROCESSED BY
CONTRACTOR Q OL o- yah L —�`$—
ADDRESS 2 6 ew/�/ti CONNACTION DATA op
CITY A6-( f TEL NO (,!�{<-rJ�� AT/T
DEPTH
STATE 'J 6 LIC C , I./ `
LICENSE NO J Y! / CLASS Z MANHOLE REFERENCE 7VrLTL
LOWER
NO DESCRIPTION OF WORK FEE TYPE OF CO N N LENGTH FROM
HOUSE SEWER CONNECTING TO ,Q�jf] Y P ML TOP L
PUBLIC SEWER 0 $500 (J�(f
SEPTIC TANK SEEPAGE PIT OR PC NO I
PITS AND/OR DRAINFIELD @ $1000 CO IMP NO JOB NO
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO 3� a
PRIVATE DISPOSAL SYSTEM 0 5300 �
CONNECT ADDITIONAL BLDG OR AFFIDAVIT WAIYER EIIEEMEMT RECORD INSTR NO DATE V
WORK TO HOUSE SEWER 0 S300
C
OVERFLOW SEEPAGE PIT DRAINFIELD
E XTN CESSPOOL DRYWELL MANHOLE® $500
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING W
SEWER OR DISPOSAL SYSTEM $3 00 STATE ENCROACHMENT D'
PERMIT NO y
INDUSTRIAL z
WASTE APPROVAL
CHARGES
OWNER S PERMIT S 2 oD
AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER APPROVALS TE INSPECTOR,4IGtjAfURf
SIGNED THIS DAY OF I9_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT_ CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
SEPTIC TANK SEEP PIT(S)
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION AND/OR DRAT NFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
LPLU
H ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ❑
MBING AND SEWERS CESSPOOL ❑ DRYWELL
HEREBY CERTIFY THATI AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
ENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
IFORNIA OR THAT I AM THE LEGAL OWNER OF AND INTEND TOSCONNECT PLUG AND
IDE IN THE A V DESeCRIBED RESIDENTIAL PROPERTY ABANDON HOUSESEWER
NATUREY BACKFILL SEPTIC TANKS ❑
F PERMRTEE !!7111... vWiW+" SEEP PIT(S) ❑ CESSPOOLS ❑
/'VALIDATION JACK R ALLEN
/4CK SUPERVISING MECHANICAL ENGINEER
M O CASH
1 fir7,5 5 6 09 JUJU 2 6 1 0 0 7 00-
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