HomeMy Public PortalAbout4958 AGNES AVE_Sewer__ CE908 3 62
76A642D APPLICATION FOR PERMI
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A LAMBIE COUNTY ENGINEER ADDRESS
COLEMAN W JENKINS SUP T OF BUILDING C
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST
LEGAL
DESCRIPTION LOT N OWNER
2� MAIL
BLOCK TRA ADDRESS
NO OF BL
DGS
SIZE OF LOT NOW ON LOT CITY TEL NO yj
USE OF
BUILDINGS DISTRICT NO GROUP BK MAP PROCESSED BY
l� �PfG
CONTRACTOR r 0 Y /
ADDRESS L CONNECTION DATA
• /'� STATION DEPTH
CITY TEL NO V
STATE LIC
LICENSE NO CLASS MANHOLE REFERENCE LOWER
NO DESCRIPTION OF WORK FEE TYPE OF CONNECTION LE GTH F M
HOUSE SEWER CONNECTING TO Y CURB PL M L TO P d
PUBLIC SEWER @ $5 00
SEPTIC TANK SEEPAGE PIT OR P` NO O
PITS AND/OR DRAINFIELD @ $10 00 CO IMP NO JOB NO u
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO w
PRIVATE DISPOSAL SYSTEM @ $3 00 O
CONNECT ADDITIONAL BLDG OR AFFIDAVIT W1I1EN EASEMEMT RECORD INSTR NO DATE
WORK TO HOUSE SEWER @ $3 00 V
OVERFLOW SEEPAGE PIT DRAINFIELD (L
EXTN CESSPOOL DRYWELL MANHOLE @ $5 00 a
A 'A HWY OR ST WIDENING Z
BANDON HOUSE
SEWER OR.,aMe"Sy.L SYSTEM @ $3 00 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL Q
WASTE APPROVAL
OWNER S PERMIT S z 00 CHRG S
AUTHORIZATION TOTAL FEE ..S CONNECTION CHARGE FEE
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTOR TO COV E THE ABOVE DESC IBED EXISTIN DWELLING
TO THE PUBLIC APPROVALS DYE INS TOR S SIGNATURE
SIGNED THIS DAY OF 1 -
OWNER OR NEW HOUSE SEWER
OWNERS AGENT_
CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
SEPTIC TANK SEEP PIT(S)
1 HEREBY ACKNOWLEDGE THAT I E READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTYORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
LICENSEDAS REQUIRED By
LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF AND INTEND TO DISCONNECT PLUG AND
RESIDE IN THE ABOVE SCRIBED RESIDENTIAL PROPERTY ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMITTEE TEl ❑
SEEP PIT(S) CESSPOOLS
VALIDATION JACK R ALLEN
SUPERVISING MECHANICAL ENGINEER
CK M O CASH
3 4'0' MR17 1 0 D 5 GO- q