HomeMy Public PortalAbout4835 AGNES AVE_Sewer_6/26/1970_ QVJ24 bd#P �= &oelG Pj 2s
76A6420• . •
CEB081REV.6/781
OPs APPLICATION- FOR PERMIT
SEWER - SEWAGE DISPOSAL
COUNTY OF LOS ANGELES BUILDING AND SAFETY
FOR APPLICANT TO Flll IN DISTRICT NO. GROUP MAP d:ZSSED BY
BK PG,
BUILDING �• �' �.% (/}(//) ei' `�
ADDRESS \.-
CONNECTION DATA
LOCALITY
NEAREST STATION DEPTH
CROSS ST. Z L,;
UPPER
MANHOLE REFERENCE LOWER
OWNER jr -eL TYPE OF CONNECTION ENGTH FROM
MAIL ��.�7 Y. CURB P.L. M.L.TO P.L.
ADDRESS
P.C.NO.
CO.IMP.NO. JOB NO.
CITY TEL.NO.
LEGAL TRUNK PERMIT NO. ROAD PERMIT NO.
DESCRIPTION LOT NO.
AFFIDAVIT I WAIVER EASEMENT I RECORD.INSTR.NO. DATE
BLOCK TRACT
NO.OF BLDGS.
SIZE OF LOT NOW ON LOT HWY.OR ST.WIDENING
USE OF
BUILDINGS STATE ENCROACHMENT
PERMIT NO.
CONTRACTOR INDUSTRIAL
WASTE APPROVAL
ADDRESS CHARGES
CONNECTION CHARGE FEE
CITY TEL.NO.
STATE LIC. REIMBURSEMENT FEE
LICENSE NO. CLASS
NO. DESCRIPTION OF WORK FEE APPROVALS DATE INSPECTOR'S SIGNATURE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER
SEPTIC TANK,SEEPAGE PIT OR NEW HOUSE SEWER
PITS AND/OR DRAINFIELD CONNECT
AL
HOUSE SEWER CONNECTING TO BUILDING OR WORK
PRIVATE DISPOSAL SYSTEM
CONNECT ADDITIONAL BLDG.OR SEPTIC TANK,SEEP,PIT(S)
WORK TO HOUSE SEWER j AND/OR DRAINFIELD
OVERFLOW SEEPAGE PIT.DRAINFIELD CESSPOOL ❑ DRYWELL❑
EXTN.,CESSPOOL,DRYWELL,MANHOLE
ALTER.REPAIR OR ABANDON HOUSE ALTER,REPAIR.SEWER OR
SEWER ORD ISPOSAL SYSTEM SEWAGE DISPOSAL SYSTEM
DISCONNECT PLUG AND
ABANDON HOUSE SEWER
BACKFILL SEPTIC TANKS❑
Permit S SEEP,PITIS)❑ CESSPOOLS❑
OWNER'S VALIDATION
AUTHORIZATION TOTAL FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER.
SIGNED THIS DAY OF 19_
OWNER OR
OWNERS AGENT
ADDRESS
IHEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CZ) O N
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY (SAI O O O I)�J
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. "`� O O O
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR (v — O ..a
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF,AND INTEND TO RE > g O ;O
SIDE IN,THE ABOVE DESCRI D RESIDENTIAL PR ERTY.
SIGNATURE 'o CD 0
OF�PE R M ITTE �'-' (iH