HomeMy Public PortalAbout5009 AGNES AVE_Sewer_0 ,
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COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A LAMBIE County Engineer ADDRESS ///d
WILLIAM A JENSEN Sup t of Building
LOCALITY /
E.RE
CROSS SST
FOR APPLICANT TO FILL IN
LEGAL
DESCRIPTION LOT NO OWNER
MAIL
BLOCK TRACT �J ADDRESS
NO OF SLOGS
SIZE OF LOT NOW ON LOT CITY TEL NO
USE OF »
BUILDINGS DISTRICT NO GROUP MAP PROCESSED BY
SK
PG
CONTRACTOR
ADDRESSJJ CONNECTION DATA
CITY TEL N04-7 L/ dSTATION DEPTH
�
i/ ❑ STATE UPPER
REGISTRATION NO
3 / � ❑ COUNTY MANHOLE REFERENCE LOWER
NO DESCRIPTION OF WORK FEE TYPE OF CON ION LENGTH FROM
HOUSE SEWER CONNECTING TO Y :11-B P L M L TO P L
PUBLIC SEWER @ $5 00 /1
0.
SEPTIC TANK SEEPAGE PIT OR PC NO V
PITS AND/OR DRAINFIELD @ $1000 CO IMP NO JOB NO V
HOUSE SEWER CONNECTING TO TR K O D PERMIT NO 99
PRIVATE DISPOSAL SYSTEM $3 00
CONNECT ADDITIONAL BLDG OR AFFIDAvTT WPI ER EASEMENT RE ORD INSTR NO DATE
WORK TO HOUSE SEWER @ $300
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL MANHOLE @ $5 00 y
ALTER REPAIR OR ABANDON HOUSE HWY ST WIDENING �Ly
SEWER OR DISPOSAL SYSTEM @ S300-- STATE ENCRO ENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT S z 00 CHA
AUTHORIZATION I TOTAL FEECONNECTION 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 DATE INSPECTOR S SIGNATURE
SIGNED THIS DAY OF -19-
OWNER
9_OWNER OR NEW HOUSE SEWER
OWNERS AGENT_ CONNECT ADDITIONAL d/
ADDRESS BUILDING OR WORK 3
SEPTIC TANK SEEP PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING ElPLUMBING AND SEWERS CESSPOOL El DRYWELL
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF AND INTEND TO DISCONNECT PLUG AND
RESIDE IN THE ABOVE DESCRIBED RESIDENTIAL PROPE T ABA
HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMITTEE SEEP PIT(5) ❑ CESSPOOLS ❑
VALROBERT A WOOD
M O
CK M /--C� SUPERVISING MECHANICAL ENGINEER
I
E.fiuJo 2 9 7 1n nPR 5 1 0 D 5 00-
-._
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