HomeMy Public PortalAbout5118 AGNES AVE_Sewer_0 CEliv
76A 642D 12 aBi
APPLICA'T'ION FOR PERMIT
78A 8
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION FAR
JOHN A LAMBIE COUNTY ENGINEER /
COLEMAN W JENKINS SUP T OF BUILDING
FOR APPLICANT TO FILL IN
IN
L GAL � Iw'
DESCRIPTION LOT NO d' Q!U OWNER ehAA A A PL, 14 om
MAIL
BLOCK TRACT ADDRESS / C
NO OF SLOGS
SIZE OF LOT NOW ON LOT CITY'QA TEL NO
USE OFI DISTRICT NO GROUP MAP PROCESSED BY
BUILDINGS
1. IS /^ PO
CONTRACTOR
ADDRESS v CONNECTION DATA
/ /
0 STAT DEPTH /
CITY ♦ TEL NO le
STATe LIC MANHOLE EFEREN E UPPER
LICENSE NO CLASS 7V CC
LOWER
NO DESCRIPTION OF WORK FEE P Oir CONNECT110PI LENGTH FROM
HOUSE SEWER CONNECTING TO A Y C L _ M L TO P L i S"/
PUBLIC SEWER @ $5 00 Q H
SEPTIC TANK SEEPAGE PIT OR P C NO
PITS AND/OR DRAINFIELD @ $1000 CO IMP NO JOB NO
HOUSE SEWER CONNECTING TO �-
PRIVATE DISPOSAL SYSTEM @ S3 00 TRUNK PERMIT NO ROAD PERMIT NO J C�j� CD
CONNECT ADDITIONAL BLDG OR AFFIDAVIT rvll EASENENT RECORD INSTR NO DATE OU
WORK TO HOUSE SEWER $300
d'
OVERFLOW SEEPAGE PIT DRAINFIELD 0
EXTN CESSPOOL DRYWELL MANHOLE @ $500
F-
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING V
SEWER OR DISPOSAL SYSTEM I @ $300 L.LJ
STATE ENCROACHMENT 0-
PERMIT
PERMIT NO N
Z
INDUSTRIAL
WASTE APPROVAL
OWNER S PERMIT s i 00 CHARGES
AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEE ,14
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTOR TQ CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER APPROVALS DATE INSPECTOR S SIGNATURE
SIGNED THIS DAY OF 1g_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT_ CONNECTADDITIONAL
ADDRESS
BUILDING OR WORK
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION SEPTIC TANK SEEP PIT(S)
AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ElPLUMBING AND SEWERS CESSPOOL ❑ DRYWELL
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
L'CC
NSEDAS 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 PROPERTY ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PER MTTTEE SEEP PIT 15) ❑ CESSPOOLS ❑
ALIDATION JACK R ALLEN
cK M o CASH SUPERVISING MECHANICAL ENGINEER
6 1'*�o AFR29 1 0 D 7 00- z
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