HomeMy Public PortalAbout4922 AGNES AVE_Sewer_6/19/1998 4 24650 INSERT
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r COUNTY OF LOS ANGELES t SEWER—SE AGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEERBUILDIN
' BUILDING AND SAFETY DIVISION' ADDRESSG °Z `+
LO_HN A LAMBIE County Engineer _
W LnIM A JENSEN Sup t of Building 4 LOCALITY
NEAREST r r 1
FOR APPLICANT TO FILL IN CROSS
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LEGAL 01
DESCRIPTION LOT NO ✓ V OWNER r +t
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BLOCK TRACT �. MAIL
S P ADDRESS -r {
NO OF BLDGS F r
SIZE OF LOT NOW ON LOi' CITY TEL NO
USE OF _
BUILDINGS - DISTRICT NO GROUP ° MAP PROCE D BY
BK PG
CONTRACTOR
ADDRESS i CONNECTION DATA
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CITY TEL NO �� STATION DEPTH
t 1
STATE ,MANHOLE REFERENC R
REGISTRATION NO �m % ® COUNTY
N >! I DESCRIPTION OF WORK FE a
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3 00 f TYPE OF CONNECTION LENGTH FROM of
SEPTIC TANK SEEPAGE PIT OR Y CURB P 12 i M L TO P L OG.
+ PITS AND/ORcDRAIN FIELD @ 33 00
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN" CESSPOOL DRYWELL @ $2 00
HOUSE SEWER CONNECTING TO P C NO
PRIVATE DISPOSAL SYSTEM @ $1 00 CO IMP NO JOB NO �.
CONNECT ADDITIONAL BLDG OR Iti'
WORK TO HOUSE SEWER @ S1 00 TRUNK PERMIT NO ROAD PERMIT NO U
ALTER REPAIR OR ABANDON HOUSE T+ STATE ENCROACHMENT
+ SEWER OR DISPOSAL SYSTEM @ $100 PERMIT NO O
INDUSTRIAL
I WASTE APPROVAL a
y s CHARGES
OWNER S PERMIT S r 2 00 CONNECTION CHARGE FEE
fi
AUTHORIZATION TOTAL FEE 0-0 REIMBURSEMENT FEEHAVE «
11
TMED CON
RACTOR TO CIONNECTLTHE ABOVE ESCRI ED EXISTING S DATE A CONTRACT W TH THE HEREIN ADWELLING APPROVALS - DATE INSPECTOR S SIGNATURE {
TO THE PUBLIC SEWER
SIGNED THIS D/ 19= NEW HOUSE SEWER f [/
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDINGOR WORK .-T r-
6 _
ADDRESS r SEPTIC TANK SEEP PIT(S) T
AND/OR DRAINFIELD
I�HEREBY ACKNOWLEDGE THAT 1 HAVE REArTHIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL ❑ ^ !' ��
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWER OR
PLUMBING AND SEWERS A s — SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTEEEJJJ222ED /OR DISCONNECT PLUG AND
LICENSED AS REQUIRED+ LOS ANGELES COUNTY /SAD STATE OF ABANDON HOUSE SEWER-
OR L
CALIFORNIA THAT 1 AM THE LEGAL NER/p�P HE ABOVE '
DESCRIBED RESIDENT OPERTY w BACKFILL SEPTIC TANKS ❑ `
SIGNATURE
SEEP PITS ❑ CESSPOOLS ❑
OF PERMITTE
di
OF
VALIDATION ROBERT A WOOD
` SUPERVISING MECHANICAL ENGINEER `
CK M 0� CASH
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