HomeMy Public PortalAbout4916 AGNES AVE_Sewer_6/27/1956_sewer connection t �
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IOWFOR PERMIT
DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Deportment of County Engineer
County of Los Angeles BUILDING
WM J FOX COUNTY ENGINEER ADDRESS ! (p
CASSATT D GRIFFIN SUP T OF BUILDING LOCALITY �7
FOR APPLICANT TO FILL IN NEAREST
CROSS ST
ALEG
DESCRIPTION
LOT NO // OWNER �Gr►, � L
BLOCK TRACT MAIL D
ADDRESS
NO OF BLDGS
_SIZE OF LOT NOW ON LOT CITY TEL NO
USE OF
BUILDINCS /V ' DISTRICT NO GROUPIS
MAP
j BK PG
114 CONTRACTOR CA � � � 7 S:
ADDRESS 9_2 W I* CONNEECTION DATA
CITY ' TEL NO STATION DEPTH
(� J_ Rr STATE MANHOLE REFERENCE UPPER
REGISTRATION NO ❑ COUNTY
NO DESCRIPTION OF WORK FEE
C
HOUSE SEWER CONNECTING TO I� � y TYP T CURB P L- M L TO P LECTION LENGTH FROM [7 V �'
PUBLIC SEWER @ $ 3 50 d
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 100 _
CONNECT ADDITIONAL BLDG OR / oL✓ PC NO
WORK TO HOUSE SEWER 100 CO IMP NO 7 JOB NO
ALTER OR REPAIR EXISTING r
SEWER ORDS°OSAL SYSTEM 1 00 TRUNK PERMIT NO ROAD PCR0.'IT NO
DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT
AND/OR DISPOSAL SYSTEM 1 00 PERMIT NO
SEPTIC TANK SEEPAGE PIT OR
PITS AND/OR DRAINFIELD { 00 INDUSTRIAL
CESSPOOL DRYWELL WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2 00 CHARGES
t
$ I 00 CONNECTION CHARGE FEE
OWNER S PERMIT
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
IHAVE MED CON
TRACTORTOCONNECT DATE THE ABOVE CTED WDESCRIBED EXISTING ITH THE HEREIN A DWELLING APPROVALS DATE INSPECTOR S SIGNATURE
TO THE PUBLIC SEWER
SIGNED THIS DAY OF 19_ NEW HOUSE SEWER
OWNER OR ''��^n w- ^- 7 '7��1 L+ / � CONNECT ADDITIONAL I
OWNERS AGENT BUILDING OR WORK
SEPTIC TANK SEEP PIT(S)
ADDRESS AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL(:IAND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND' STATE LAWS REGULATING
PLUMBING AND SEWERS ALTER REPAIR SEWER OR I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR SEWAGE DISPOSAL SYSTEM
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABO%E ABANDON HOUSE SEWER
DESCRIBED RESIDENTIAL PROPERTY I BACKFILL SEPTIC TANKS❑
SEEP PIT($) ❑ CESSPOOLS❑
SIGNATURE
OF PEPMITTEE-499�Z-I�zz",
's
WILLIAM J FOX COUNTY ENGINEER _ VALIDATION R A WOOD CHIEF PLBG INSPECTOR
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_ C07 4 X3 `2- JUN27 4 w4 50 �
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