HomeMy Public PortalAbout5120 AGNES AVE_Sewer_2/1/1954 v
DFPARTMI:NT OF COUNTY ENGLNIMR SEWER-SEWAGE DISPOSAL
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
WILLIAM J FOX, COUNTY ENGINEER I BUILDING :5
ADDRESS 1 /V
FOR APPLICANfq TO FILL IN LOCALITY
BUILDINGS/ CNEAREST
ROSSST
ADDRESS
T"� �/ DISTRICT NO SERIAL NO PERMIT NO
LOCALITY A �_! /7 7�c
NEAREST J
CROSS ST
RECEIVED BY Ready for Inspection DAY ISSYED
OWNER sY
MAIL USE ZON F-V OCCUPANCY 16AP
ADDRESS P/ SK PG
CITY TEL.NO 7449
/ � �-
CONTRACTOR' i r /�/, CO IMP NO 130 6r
ADDRESS JOB NO
CITY /&4!!?�ZTEL NO�f /( TRUNK PERMITATE
NO
REGISTRATION NO 1 COUNTY ROAD PERMIT NO
LEGAL �1LD T
STATE ENCROACHMENT
DESCRIPTION LOT NO
PERMIT NO
BLOCK TRACT INDUSTRIAL
WASTE APPROVAL
SIZE OF LOT NO OF BLDGS
NOW ON LOT Z)I CHARG
X/OO
USE OF
/�r /
BUILDINGS r�P h& CONNECTION CHARG'EXEE
NO DESCRIPTION OF WORK FEE
REIMBURSEMENT FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ >i 350 ,JPO RECEIPT NO DATE I BY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 100
CONNECT ADDITIONAL BLDG OR EXCEPTION R ORDEO
WORK TO HOUSE SEWER 1 00
At OR REPAIR EXISTING NO DATE BY
SEWER OR DISPOSAL SYSTEM 1 00
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1 00 CONNECTION DATA
SEPTIC TANK SEEPAGE PIT OR � /.
PITS AND/ORDRAINFIELD 200 STATION DEPTH
CESSPOOL—DRYWELL /
SPECIAL CONDITIONS ONLY 200 9.�e ��MA UPPE EFERENCE� LOWER
TYPE OF ECTIO LENGTH FROM ,
OWNERS PERMIT $ 1 00 0 CURAD cm ML TOP L
AUTHORIZATION TOTAL FEE
IHAVE CONTRACTOIS DATE R TO CONNECT THTED WITH THE E ABOVE DESCRIBED EXISTING AED PPROVALS INSPECTOR S SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER ��
SIGNED THIS „l__ DA OF a e_ _ _ _ 19 � NEW HOUSE SEWER "�G31 o C Ar Is
OWNER OR CONNECT ADDITIONAL
OWNERS AGEN� _ / _ _ _ _ BUILDING OR WORK
ADDRESS AND/OR DRASEPTIC INF ELD SEEP PIT(S)
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLI CESSPOOL[:] DRYWELL
CA
TIONAND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER REPAIR SEWER OR
REGULATING PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT IAN PROPERLY REGISTERED DISCONNECT PLUG AND
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOUSE SEWER
AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN
ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY BACKFILL SEPTIC TANKS _
SIGNATURE SEEP PIT(S)� CESSPOOLS� SC' r0 Cf, .g
OF PERMITTEE
76A642A 663 7/53 �'