HomeMy Public PortalAbout4938 AGNES AVE_Sewer_1/13/1965_ CITY OF T&9U CITY
:E808 10 63 APPLICATION FOR PERMIT
6A642D
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A LAMBIE County Engineer ADDRESS
4938 Agnes
WILLIAM A JENSEN Sup t of Building e
LOCAL TY Temple City
FOR APPLICANT TO FILL IN
CROSSSST L*wer Azusa Rdm
LEGAL
I DESCRIPTION LOT NO OWNER
MAIL
BLOCK TRACT ADDRESS Same,
NO OF BLDGS
SIZE OF LOT NOW ON LOT CITY TEL NO
USE OF DISTRICT NO GROUP MAP PROCESSED BY
BUILDINGS 08
r BK PG
CONTRACTOR ere lumbi 1 V
ADDRESS 2845 N. CONNECTION DATA
CITY F'.Z MentS TEL NO GI 24600 STATION DEPTH J
REGISTRATION N0229768 Ct»36 19 STATE❑ COUNTY MANHOLE REFERENCE UPPER
LOWER
NO DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y CURB P L M L TO P L
PUBLIC SEWER @ $5 00
SEPTIC TANK SEEPAGE PIT OR J C NO O
PITS AND DRAINFIELD S1000 CO IMP NO OB NO t l
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO 0'
PRIVATE DISPOSAL SYSTEM @ 33 00 0
CONNECT ADDITIONAL BLDG OR AFFIDAVIT I WAIVER I 1111M[NT RECORD INSTR NO DATE
WORK TO HOUSE SEWER @ $300 U
OVERFLOW SEEPAGE PIT DRAINFIELD W
EXTN CESSPOOL DRYWELL MANHOLE @ E5 00
ALTER REPAIR R ABANDON HOU;�@
HWY OR ST WIDENING H
SEWER OR DISPOOSAL SYSTEM �$300 STATE ENCROACHMENTxi sting Z
PERMIT NO 40 1
INDUSTRIAL
WASTE APPROVAL
OWNER S PERMIT $ 2 00 HARGES
AUTHORIZATIONTOTAL FEE 5 CONNECTION CHARGE FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER APPROVALS DATE INSPECTOR S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT
CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
SEPTIC TANKSEEP PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER RE AM SEWER dR
LICENSED AS REQUIRED BY LOS ANGVa COUNTY AND STATE OF /Ni J
CALIFORNIA OR THAT I AM THE LEG WN O R INTEND TO DISCONNECT PLUG AND D
RESIDE IN THE AB 7DESC YB ED E �DE IAL PR ERTY ABANDON HOUSE SEWER
SIGNATURE BACKFILL TSEPTIC TANKS C3OF PERMITTEE SEEP PIS) ElCESSPOOLS ❑
VALIDATION ROBERT A wood
SUPERVISING MECHANICAL ENGINEER
CK M O CASH
LfCo 7s2a— JAN 1310 D 5.00-