HomeMy Public PortalAbout5014 AGNES AVE_Sewer_8/10/1959_house sewer connection to public sewer D
9&E 668 3 9S
APPLICATION FOR PERMIT
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DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL.
Department of County Engmeer
County of Los Angeles BUILDING
WM J FOX COUNTY ENGINEER ADDRESS
` CASSATT D GRIFFIN SUP T of BUILDING LOCALITY
FOR APPLICANT TO FILL TM
NEAREST
CROSS STLEGAL
DESCRIPTION LOT NO I(q �W D� OWNER
BLOCK TRACT �� MAIL
ADDRESS
NO OF BLCITY TEL NO
SIZE OF LOT NOW ON LOTT
USE OF �.c+r�F.vGE
BUILDINGS DISTRICT NO GROUP MAP
P
CONTRALTO
S 6
ADDRESS ' CONNECTION DATA
CITY TEL NO STATION �0 DEPTH
ATE MANHOLE REFERENCE m L WE
REGISTRATION NO r7v/ ❑ COUNTY
NO DESCRIPTI(AOF WORK FEE
TYPE CAOrtlftECTION LENGTH FROM .,
HOUSE SEWEP CONNECTING TO -
Y CURBJ P L M L TO P L
PUBLIC SEWER Q
hOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 100 _
CONNECT ADDITIONAL BLDG OR /��� P C NO
WORK TO HOUSE SEWER 1 00 CO IMP NO JOB NO
ALTER OR REPAIR EXISTING �7���
SEWER OR DISPOSAL SYSTEM 1 00 TRUNK PERMIT NO ROAD PERMIT NO
DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT
AND/OR DISPOSAL SYSTEM 1 00 PERMIT NO
SEPTIC TANK SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 2 00 INDUSTRIAL
CESSPOOL DPYWELL
WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2 00 CHARGES
OWNER S PERMIT CONNECTION CHARGE FEE
S 00
AUTHORIZATION TOTAL FEE Irz) REIIiBURSEMENT FEE
TRACTORHAVE TTOS CONNECTDATE ONTRTHEAABOVECTED WDESCR BEDITH THE H EXISTING A
D" CONAPPROVALS DATE INSPECTOR SSIGNATURE
TO ThE PUBLIC SEWER -� Y/_ /^
alCC�� NEW HOUSE SEWER Jl ,J
SIGNED THIS D4Y OF � 1 � I v
OWNER O4 �/ � CONNECT ADDITIONAL
OWNERS AGE _ ���/7�L- BUILDING OR WORK `
SEPTIC TANK SEEP PIT(S)
ADDRESS AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION CESSPOOL❑ DRY WELL[IAND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPL.Y
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND ST E 0 DISCONNECT PLUG AND
CALIFORNIA hR THAT I AM T E LEGAL 0 R OF H E ABANDON HOUSE SEWER
I(B�p'� 1 PROP Y BACKFILL SEPTIC TANKS❑
��p�/Fy�1�A . SEEP PIT(S) E3 CESSPOOLS❑
'SIGNATURE
OF PERMITTEE -e�G
WILLIAM J FOX COUNTY ENGINEER VALIDATION R A WOOD CHIEF PLBG INSPECTOR