HomeMy Public PortalAbout5113 AGNES AVE_Sewer_7/20/1961_house sewer connection to public sewer CVS 24650 INS
CE808 a eD
`76A642D APPLICATION FOR PERMIT ,-
8A842COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING )
ADDRESS
JOHN A LAMBIE County Eng�neer �� r
WILLL?tM A JENSEN Supt of Bmld�ng LOCALITY
FOR APPLICAN TO FILL IN NEAREST il C�
CROSS ST /i ✓
LEGAL
DESCRIPTION LOT NO OWNER/ t
BLOCK TRACT MAIL
ADDRESS
NO OFBLDGS
SIZE OF LOT NOW ON LOT CITY TEL NO
USE
BUILDINGS BK PG DISTRICT NO GROUP MAP PROCESSED BY
CONTRACTOR
ADDRESS 3/5 s r— CONNECTIO14 DATA
CITY h� TEL NO Q &, O y STATION DEPTH
STATEMANHOLE REFERENCE
REGISTRATION NO COUNTY LOWER
NO DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3 00 LL TYPE OF CONNECTION LENGTH FROM
SEPTIC TANK SEEPAGE PIT OR y CURB P L M L TO P L
PITS AND/OR DRAINFIELD @ $3 00
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL @ $2 00
HOUSE SEWER CONNECTING TO P C NO
PRIVATE DISPOSAL SYSTEM @ $1 00 CO IMP NO JOB NO >•
CONNECT ADDITIONAL BLDG OR TRUNK PERMIT NO ROAD PERMIT NO Q
WORK TO HOUSE SEWER @ $1 00 U
ALTER REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
SEWER OR DISPOSAL SYSTEM @ $1 00PERMIT NO W
O
INDUSTRIAL U
WASTE APPROVAL W
CHARGES M
OWNER S PERMIT $ 2 00 CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE REIMBURSEMENT FEE
I HAVE AT DATE ACON
TRACTOR TO CIONNECT THE ABOVET DESCRIBED EXISTINGWITH THE HEREINpMED DWELLIING APPROVALS DATE INSPECTOR S SIGNATURE
TO THE PUBLIC SEWER
SIGNED THIS DAY OF 19_ NEW HOUSE SEWER c9
OWNER OR /)/i CONNECT ADDITIONAL
OWNERS AGENT ! BUILDING OR WORK
ADDRESS SEPTIC TANK SEEP PIT(S)
AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION --
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL [I DRYWELL ❑ i
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDEN A PROPERTY BACKFI LL SEPTIC
TANKS ❑
SIGNATURE SEEP PITS [I CESSPOOLS ❑
OF PERMITTE
OF VALIDATION ROBERT A WOOD
CIL M o CASH SUPERVISING MECHANICAL ENGINEER
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