HomeMy Public PortalAbout5210 AGNES AVE_Sewer_0 8&E
A °6 81155 APPLICATION FOR PERMIT 1
DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Department of County Engineer
County Of Los Angeles BUILDING 77/4
JOHN A LAMBIE COUNTY ENGINEER ADDRESS
® CASSATT D GRIFFIN SUP T OF BUILDING LOCALITY
FOR APPLICANT TO FILL IN CROSS ST 11974
LEGAL - / OWNER
/
DESCRIPTION LOT NO 7 �►^
BLOCK TRACT MAIL
ADDRESS
/t�
NO OF BLDGS
SIZE OF Loi?Q7 NOW ON LOT CIT"k-7, C TEL NO ,
USE OF V
BUILDINGS DISTRICT NO GROUP MAP
�C.�
BK PG
CONTRACTOR y
CONNECTION DATA
ADDRESS
STATIONL a DEPTH (9
CITY TEL NO
❑ STATE MANHOLE REFERENCE r UPPER
REGISTRATION NO /NO DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO TYPE OF TION LENGTH FROM
PUBLIC SEWER
@ $350 Y URB PL ML TOPL s
SEPTIC TANK SEEPAGE PIT OR
PITS AND/OR DRAINFIELD Q $3 00
OVERFLOW SEEPAGE PIT DRAINFIELD CO IMP NO Q s OC NO
B NO J
EXTN CESSPOOL DRYWELL MANHOLE Q $2 00
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM Q $1 00 TRUNK PERMIT NO ROAD PERMIT NO
CONNECT ADDITIONAL BLDG OR STATE ENCROACHMENT
WORK TO HOUSE SEWER Q $1 00 PERMIT NO
ALTER REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM Q $100 WASTE APPROVAL
/ CHARGES
CONNECTION CHARGE FEE
OWNER S PERMIT $ 1 00
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON APPROVALS DATE INSPECTOR SSIGNgTURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEry)_VE �j NEW HOUSE SEWER
SIGNED THIS ` AY OF � 19 CONNECT ADDITIONAL
OWNER OR ✓ BUILDING OR WORK
OWNERS AGENT SEPTICTANK SEEP PIT(S)
ADDRESS.y2-10 Gk0_,S, CITY AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I AVE REALAGREETO
CATION CESSPOOL❑ DR
YWELL❑
AND STATE THAT THE ABOVE IS CORRECT ANOMPLYWITH ALL COUNTY ORDINANCES AND STATELATING ALTER REPAIR SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT I AM PROPERLY AND/ORDISCONNECT PLUG ANDLICENSED AS REQUIRED BY LOS ANGELES COATE OF ABANDON HOUSE SEWDCALIFORNIA OR THAT I AM THE LEGAL OWABOVE
ER
DESCRIBED RESIDENTIAL PROPERTY BACKFILL SEPTIC TANKS❑
SIGNATURE SEEP PIT(S) ❑ CESSPOOLS .arC
OF PERMITTEE "An';_4 I
JOHN A LAMBIE COUNTY ENGINEELIDATION ROBERT A WOOD CHIEF PLBG INSPECTOR
CASH
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