HomeMy Public PortalAbout4908 AGNES AVE_Sewer_0 81
76AG42D APPLICATION FOR PERMIT
6A842
COUNTY OF LOS ANGELES SEWER SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DMSION BUILDING
JOHN A, LAMBIE County En ser ADDRESS
WILLIAM A JENSEN Supt of Building_ LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST
LEGAL OWNER
DESCRIPTION LOT N
BLOCK TRACTKI47 MAIL
ADDRESS
a NO OF BLDGS IF
SIZE OF L ✓NOW ON LOT CITY TEL NO
USE OF
BUILDINGS BK P6 DISTRICT NO GROUP YAP PROCES BY
CONTRACTOR
ADDRESS ofCONNECTIO DATA
CITY TEL NO/,`JyC (9 ION DEPTH i
STATE MANHOLE R FERENCE
REGISTRATION NO COUNTY WER
No DESCRIPTIO OF FEE 4
HOUSE SEWER CONNECTING TO Lf,
PUBLIC SEWER Q S 00 TYPE OF CONNECTION L NGTN FROM
PETS AND/OR DRAENFGELDT OR 0 213 00 Y CURB P L Y L TO P L
EXTNFLC SSPOOLGDRYWELLAINFIELD 1200 }
CL
HOUSE SEWER CONNECTING TO ^^ P C NO 0
PRIVATE DISPOSAL SYSTEM @ 1100 CO IMP NO C� JOB NO U
CONNECT ADDITIONAL BLDG OR TRUNK PERMIT NO ROAD PERMIT NO
WORK TO HOUSE SEWER 100
SEWER OR PAIRDISPO R ABANDON EHOUSE 1 00 STATE ENCROACHMENT O
PERMIT NO IV
INDUSTRIAL Cl
WASTE APPROVAL N
CHARGES ?
OWNERS PERMIT : 2 00 CONNECTION CHARGE FEE
AUTHORIZATION 1 TOTAL FEE REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN N MED CON
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS ATE INSPECT R S SIGNATURE
TO THE PUBLIC SEWER 1
SIGNED THIS DAY OF 19- NEW HOUSE SEWER a�
OWNER OR --11, CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADDRESa SEPTIC TANK SEEP PIT($)
AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL [3DRYWELL
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEII
1 HEREBY CERTIFY TH 1 M PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED ANGELES COUNTY AND STATE.OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT A THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESID P PERTY SACKFI L SEPTIC
TANKS
SIGNATURE
II6OPERMITTER
VALIDATIO
ROI 3ERT A WOOD
CK. M 0 CAftl SUPERVISING MECHANICAL BNGINEM
U;Cc 1 6 2 2 % APR 2 i 0 D , 7 0 0
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