HomeMy Public PortalAbout4910 AGNES AVE_Sewer_4/23/1979_sewer connection r r J/
CE80836I
76A642D APPLICATION FOR rERMITArn t%SCOUNTY OF LOS ANGELES SEWER-SEWAG DPOSAI,.
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING 0 da
OIiN A LAMBIE County Eagg��nnear
ADDRESS
VALLIAM A JENSEN Supt of Buildhag_ LOCALITY .G &
NEAREST
FOR APPLICANT TO FILL IN CROSS ST
LEGAL
DESCRIPTION LOT NO OWNER
BLOCK TRACT MAIL
ADDRESS I
NO OF BLDGS
SIZE OF LOT 5'6 �D U NOW ON LOTCITY TEL NO
USE OF
BUILDINGS DISTRICT NO GROUP MAP PROCESSED BY
CONTRACTOR .� BK p6
ADDRESS CONNECTION DATA
CITY TEL NO � L� STATION �. S_ DEPTH
3STATE MANHOLE REFERENCE Q, Fy UPPER
REGISTRATION NO COUNTY o r�
No I DESCRIPTION OF _ FEE 0
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ TYPE OF CO ECTION LfkGTH FROM
SEPTIC TgNK SEEPAGE PIT OR CURB P L M L TOP L
PITS AND OR DRAINFIELD 33 00
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL @ $2 00 Ct
HOUSE SEWER CONNECTING TO t P C NO 0
PRIVATE DISPOSAL SYSTEM @ $100 CO IMP NO S JOB NO 0
CONNECT ADDITIONAL BLDG OR TRUNK PERMIT NO ROAD PERMIT NO
WORK TO HOUSE SEWER S1 00 CiG
SEWERREPAIR
R DISPOSAL SYSTEM NOOSE @ SI 00 STATE ENCROACHMENT 0
PERMIT NO V
INDUSTRIAL W
WASTE APPROVAL d
N
CHARGES Z
OWNERS I PERMIT E 2100 CONNECTION CHARGE FEE
AUTHORIZATION FTOTAL FEB 7,100 REIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON PPR
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING AOVALS DTE INSPECTOR S SIG T
TO THE PUBLIC SEWER
SIGNED THIS DAY OR- NEW HOUSE SEWER f�
OWNER OR CONNECT ADDITIONAL 7
OWNERSAGENT BUILDING OR✓PORK
ADDRESS SEPTIC TANK SEEP PIT(S)
AND/OR DRAINFIELD
AHEREBY ACKNOWLEDGE THAT I. HAVE READ THIS APPLICATION _STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL DRYWELL
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTE
ll
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OltDISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR TAT AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESID TI PROPERTY BACKFILL
S ❑ TANKS 0❑LS
SIGNATURE
OF PERMITTE
VAI.IDATTQROBERT A WOOD
CK M 0 CUR SUPERVISING MECHANICAL,ENGINEER
LA-;o J 5 2 0 %-04 AM 2 3 1 0 0 70 0 �°