HomeMy Public PortalAbout5021 AGNES AVE_Sewer_12/17/1963_house dewer connection to public sewer 8AG42D D °z
7APPLICATION FOR PER
78A 84 'I
COUNTY OF LOS ANGELES SEWER/SEWAGE DISPOSAL IuI
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A LAMBIE County Engineer ADDRESS
WILLIAM A JENSEN Sup t of Buifdmg
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN RO55 9T
LEGAL
DESCRIPTION LOT NO O OWNER
MAIL
BLOCK TRACT ADDRESS
NO OF BLDGS
SIZE OF LOT NOW ON LOT CITY TEL NO
USE OF DISTRICT NO GROUP MAP PROCESS BY
BUILDINGS �+� BK PG
CONTRACTOR
o� -
ADDRESS CONNECTION DATA
CITY ( / TEL NO T STATIONt174 D DEPTH f
STATE MANHOLE!!!REFERENCE
REGISTRATION NO / �/ COUNTY OWE
NO DESCRIPTION OF WORK FEE �� a
TYPE OF ION LENGTH F M
HOUSE SEWER CONNECTING TO Y CUR P L M L TO P L O
PUBLIC SEWER @ $5 00
SEPTIC TANK SEEPAGE PIT OR P C NO V
PITS AND/OR DRAINFIELD @ $1000 CO IMP NO D JOB NO
of
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NOO
PRIVATE DISPOSAL SYSTEM @ $300 f...
CONNECT ADDITIONAL BLDG OR AFFIDAVIT I WAIVER EASEMENT RECORD INSTR NO DATE W
WORK TO HOUSE SEWER @ $300 d
OVERFLOW SEEPAGE PIT DRAINFIELD fJ7
E XTN CESSPOOL DRYWELL MANHOLE @ $5 00 HWY OR ST WIDENING
ALTER REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM @ $3 00 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT $ 2 00 CHARGES
AUTHORIZATION TOTAL FEE .ail 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
TO THE PUBLIC SEWER APPROVALS DATE INSPECTOR S SIGNATURE
SIGNED THIS DAY OF 19_ /
OWNER ORNEW HOUSE SEWER
OWNERS AGENT~ v
CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
SEPTIC TANK SEEP PIT(S)
I HEREBY ACKNOWLEDGE THAT 1 HAVE RyAD THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT ND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ❑
PLUMBING AND SEWECESSPOOL RS [I DRYWELL
I HEREBY CERTIFY THAT�f AM PROPERLY ISTERED AND/OR ALTER REPAIR SEWER OR
LICENSED AS REQUIRE BY LOS ANG C NTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT /AM THE LE A't O NE OF AND INTE D TO DISCONNECT PLUG AND
RESIDE IN THE ABO ESCRIBED RES? AL ERTY
ABANDON HOUSE SEWER �
SIGNATURE ❑
OF PERMITT 47 1 BACKFILL SEPTIC TANKS
SEEP PITS) ❑ CESSPOOLI
LIDA'I'IO
CK ROBERT A WOOD
' � SUPERVISING MECHANICAL ENGINEER
M O CASH
(ACO3 6 0 01-0 DEC 17 1 0 D 7 00N
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