HomeMy Public PortalAbout5015 AGNES AVE_Sewer_8/2/1976_house sewer connection to public sewer a-t
76A 642D - CE808 - 9/73 APPLICATI FOR P MIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING ���
ADDRESS
LOCALITY
NEAREST
FOR APPLIC TO FILL IN CROSS ST
LEGAL �v / 1
DESCRIPTION LOT NO / OWNER /` /�
MAIL
BLOCK TRACT r OS
ADDRESS
NO
Q / CITY
SIZE OF LOT NOWON LOT ` L NO ^
USE OF DISTRICT NO GROUP f MAP PROC SSED BY
BUILDINGS e2loof.
BK
.�fP
CONTRACTOR /^ 7/0
ADDRESS J� CONNECTIONF� DATA
CITY V TEL NO STATION / 3 -,L-) 7
DEPTH
STATE LIC MANHOLE REFERENCE ,f-2 LOWER
LICENSE NO GLASS �7 7
NO DESCRIPTION OF WORK FEE TYPE OFC TION LENGTH FROM
HOUSE SEWER CONNECTING TO r )( Y CURB PL ML TOP L
PUBLIC SEWER 0 $7 00 T !rl
SEPTIC TANK SEEPAGE PIT OJR C NO
PITS AND/OR DRAINFIELD @ $10 GO CO IMP NO 3 V OB NO r
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO
PRIVATE DISPOSAL SYSTEM $300 V _
CONNECT ADDITIONAL BLDG OR AFFIDAVIT wAIY« [1S[N9NT RECORD INSTR NO DATE
WORK TO HOUSE SEWER $300 d
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL $5 DO Q�l
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING
SEWER OR DISPOSAL SYSTEM $300 STATE ENCROACHMENT �
MANHOLE $7 00 PERMIT NO V
INDUSTRIAL LLJ
a
WASTE APPROVAL (n
CHARGES Z
OWNERS PERMIT s o
AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEE
IHAVE 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�SIGNATU RE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
SEPTIC TANK SEEP 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 [IPLUMBClNG AND SEWERS CESSPOOL DRYWELL
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALI FCRN IA OR THAT I AM THE LEGAL OWNER OF AND INTEND TO DISCONNECT PLUG AND
RESIDE IN THE ABOY DESCRIBED RESIDENTIAL PROPERTY ABANDON HOUSE SEWER
SIGNATURE 1 AC KFILL SEPTIC TANKS
OF PEitM T r � �S}EEP PIT(S) [I CESSPOOLS ❑
VALIDATION CK M 0 SH
f
_ 3 9 940-AUG 2 10 1) 1 5.0 0 A9�