HomeMy Public PortalAbout5020 AGNES AVE_Sewer_5/10/1973_connect additional bldg to house sewer 76A 642D-�-;CE808-100 7
71 APPLICATION FOR ERM IT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION fNEAREST
UILDING Oat W QS
DDRESS / C
PMOCALITY L
FOR APPLICANT TO FILL IN ROSS ST
LEGAL 4-4
DESCRIPTION LOT NO I, OWNER
MAIL
BLOCK a r, ACT ADDRESS Q a,V k/(
r NO OF BLDGS
SIZE OF LOT NOW ON LOT rSTATION
L NO
USE OF ;i]�t
MAP PROCESSED BY
BUILDINGS BK P !
CONTRACTOR /� LADDRESS CONNECTION DATA
CITY TEL NO DEPTH
STATE LIC MANHOLE REFERENCE UPPER
LICENSE NO CLASS 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 0 $7 00
C NO
SEPTIC TANK SEEPAGE PIT OR
J
PITS AND/OR DRAINFIELD @ E1000 CO IMP NO OB NO
}
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO d
PRIVATE DISPOSAL SYSTEM @ $300 O
ONNECT ADDITIONAL BLDG OR IISIMIMT I RECORD INSTR NO DATE U
WORK TO HOUSE SEWER @ $300
OVERFLOW SEEPAGE PIT DRAINFIELD
E XTN CESSPOOL DRYWELL @ $5 00 O
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING I--'
SEWER OR DISPOSAL SYSTEM@ $300 STATE ENCROACHMENTW
MANHOLE @ $7 00 PERMIT NO ® �r s //INDUSTRIAL '' H
WASTE APPROVAL DD v� ig
OWNER S PERMIT S 3 00 CHARGES
AUTHORIZATIONTOTAL FEE 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 APPROVALS
TO THE PUBLIC SE�tl�{t DATE INSPECTOR S SIGNATURE 1
SIGNED THIS /(/ DAY OF� 19D
OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
SEPTIC TANK SEEP PIT(S)
1 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 ❑
IHEREBY 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
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF AND INTEND TO DISCONNECT PLUG AND
RESIDE IN THE AB DESCRIBED RES ENTI L PROPERTY ABANDON HOUSE SEWER
SIGNATURE
OF PERMITTEE BACKFILL SEPTIC TANKS ❑
SEEP PIT(S) ❑ CESSPOOLS ❑
VALIDATION CK M 0 CASNh
a .5 8�'3 MAY 1 0 1 0 D 600-
u