HomeMy Public PortalAbout5006 AGNES AVE_Sewer_0 62
76A64262
APPLICATION FOR PERMIT
6A642
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING �OO�
JOHN A LAMBIE County Enggweer ADDRESS
WILLIAM A JENSEN Sup t of Buwldmg C
LOCALITY
NEAREST
FOR APPMCANj TO FIL INCROSS 5T
LEGAL «—
DESCRIPTION LOT NO OWNER
MAIL /j ^
BLOCK TRACT ADDRESS !!y C1eq;i!z A27
NO rOF BLDGS
SIZE OF LOT NOW ON LOT CITY TEL N
USE OF
BUILDINGS DISTRICT NO� GROUP MAP PROCESSED BY
BK PG
CONTRACTOR 4G� � L.�
/ L 76 1
ADDRESS fv CONNECTION DATA
�y 5T ION DEPTH
CITY TEL NO/r} (� 7 7
REGISTRATION NO (/ Q _ E3 eTATE El COUNTY MANHOLE REFERENCE UPPER
NO DESCRIPTION OF WORK FEE TYPE OF CONLENGTH FROM
HOUSE SEWER CONNECTING TO Y �U PL ML TOPL0
PUBLIC SEWER @ $5 00 i
SEPTIC TANK SEEPAGE PIT OR PC NO r'
PITS AND/OR DRAINFIELD @ 31000 CO IMP NO JOB NO ��++ V
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NOy" �/ O
PRIVATE DISPOSAL SYSTEM @ $300 (J!
CONNECT ADDITIONAL BLDG OR AFFIDAVIT I WAIVER EASEMENT RECORD INSTR NO DATE
WORK TO HOUSE SEWER @ $300
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL MANHOLE @ $5 00
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING _
SEWER OR DISPOSAL SYSTEM $300 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL 47
WASTE APPROVAL
OWNER$ PERMIT $ z 00 CHARGES
AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEE
IHAVE 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 DATE INSPECTOR S 515NATURE
SIGNED THIS DAY OF 19
OWNER OR l NEW HOUSE SEWER 1
OWNERS AGENT_— G�1lA CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
SEPTIC TANK SEEP PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ❑ E3PLUMBING AND SEWERS CESSPOOL DRYWELL
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
LICENSED AS REOUIR Y LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR TH 1 A THE LEGAL OWN R OF AND I TEND TO DISCONNECT PLUG AND
RESIDE IN THE OVE ESCRIBED REST IAL P PE Y ABANDON HOUSE SEWER
TUREGN
SIOF APERMITTE / SEEP FP IT(SEP❑ TANKS C ESSPO❑OLS ❑
ALIDATIOCAS� ROBERT A WOOD
M O
SUPERVISING MECHANICAL ENGINEER
C
trl t�� i 2 0 ffi'I 1 0 D 700
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