HomeMy Public PortalAbout5004 AGNES AVE_Sewer__ CEBDB 3 62
76A842D APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING J—w4 C
JOHN A LAMBIE County Eng2 neer ADDRESS
WILLIAM A JENSEN Sup t of Building G
LOCALITY
FOR APPLIC TO FILL NEAREST
CROSS ST
LEGAL �7/
DESCRIPTION LOT NO V OWNER
MAIL /
BLOCK TRACT ADDRESS
NO OF BLDGS
SIZE OF LOT NOW ON LOT CITY <-- TEL NO
USE OF
BUILDINGS DISTRICT NO GROUP MAP PROCESSED B
B` PG
CONTRACTOR �D J�
ADDRESS Z J' CONNECTION DATA
CITY r�O TA /� DEPTH /
REGISTRATION NO h-�/ 1 �f �.,1, ` El COU NTY MANHOLE REFERENCE UPPER
NO DESCRIPTION OF WORK FEE TYPE OF CON E LENGTH FROM Q'
OUSE SEWER CONNECTING TO Y p L MIL TO P L
PUBLIC SEWER @ $5 00 v
SEPTIC TANK SEEPAGE PIT OR PC NO V
PITS AND/OR DRAINFIELD @ $1000 CO IMP NO JOB NO no///
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO
A ( O
PRIVATE DISPOSAL SYSTEM $3 00 ` 0
CONNECT ADDITIONAL BLDG OR AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE
WORK TO HOUSE SEWER @ $300
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL MANHOLE @ $500 �yy
ALTER REPAIR OR DON HOUSE HWY OR ST WIDENING Z
SEWER OR DISPOPS14YSTEM 17 @ $300 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
OWNERS✓ PERMIT $ CHARGES
AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEE
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTORTO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER APPROVALS DATE INSPECTOR S SIGNATURE
SIGNED THIS DAY OF tg_
OWNER OR �� NEW HOUSE SEWER
OWNERS AGENT_ CONNECT ADDITIONAL
ADDRESS
BUILDING OR WORK
I HEREBY ACKNOWLEDGE THASEPTIC TANK SEEP PIT(S)
T I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY I AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
LICENSED AS REgUI D BY LOS ANGLES COUNTY q D STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR T I AM THE LEGAL OWNER OF A INTEND TO DISCONNECT PLUG AND
RESIDE IN THE VE DESLRIBED RE DENTIAL R PERTY ABANDON HOUSE SEWER
SIGNATURE
OF PERMITT fill
BACKFISEEP PLTfSEp❑ TANKS
❑
VALIDATION ROBERT A WOOD
CK M O ASH
SUPERVISING MECHANICAL ENGINEER
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