HomeMy Public PortalAbout5117 AGNES AVE_Sewer_12/22/1953_19552-S house sewer connection to public sewer, addtl bldg DEPARTMENT OF COUNTY ENGINEER SEWER-SEWAGE DISPOSAL 1
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES BUILDING �f1
WILLIAM J FOX COUNTY EN13INEER I ADDRESS AG Ylto.1
FOR APPLICANT TO FILL IN LOCALITY�� C1 ' ft
BUILDING / NEAREST `
ADDRESS — Q CROSSST I vQ
LOCALITY -71 DISTRICT NO SERIAL NO PERMIT NO
a c
NEAREST U A ���.S�c� ` J
CROSS ST
RE IVED BY Ready for Inspection DATE ISSUED
OWNER` { , /l -2-a-�3
MAIL t �� ..��'' ��"
ADDRESS �-JV/17 0d USE Z E OCCUPANCY BK MAP PG
CITY TEL IdO `� �— l -TC„
CONTRACTOR CO IMP NO /30J 1,4 �+
ADDRESS _ ljll ���J Qe JOB NO
CITY TEL NO Q♦ / .2J�Y TRUNK PERMIT NO �-
6 STATE
REGISTRATION NO (/ ( !�� �� _COUNTY ROAD PERMIT NO
LEGAL O 6 l STATE ENCROACHMENT
DESCRt IPTION LOT NO PERMIT NO
BLOCK TRACT ���/ INDUSTRIAL
WASTE APPROVAL
SIZE OF LOT NO OF BLDGS�J NOW ON LOT CHARGES
USE
BUILDINGS CONNEC CHARGE FEE
1-s� �/�'—�.,.._
NO DESCRIPTION OF WORK FEE / c
REIMBURSEMENT
HOUSE SEWER CONNECTING TO
PUBLICSEWER @ $ 350 S�O RECEIPT NO ATE IBY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1 00
' CONNECT ADDITIONAL BLDG OR EXCEPTION RECORD
WORK TO HOUSE SEWER 1 00
ALTER OR REPAIR EXISTING NO DATE 6
SEWER OR DISPOSAL SYSTEM 1 00
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1 00 CONNECTION DATA
SEPTIC TANK SEEPAGE PIT OR /
PITS AND/OR DRAINFIELD 200 STATIONQ DEPTH
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 200 Gc QI C O MAN PES EFERENCE
i
TYPE OFF CONNECTION LENGTH FROM >
OWNERS FPERMIT ; t 00 ML
TO P L
AUTHORIZATION I TOTAL FEE S
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR S SIGNATURE DATE
DWELLING TO THE UBLIC SEWER rlff
SIGNED THIS AY OF I Q 19 �lj NEW HOUSE SEWER 9'G YD G-K 1 -44
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
�j � SEPTIC TANK SEEP PIT(S)
ADDRESS _ S� _ '^�'^_" AND/ORDRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI CESSPOOL[-] DRYWELL
CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER REPAIR-SEWER OR
REGULATING PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED DISCONNECT PLUG AND
"AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOUSE SEWER
AND STATE OF CALIFORNIA OR THAT 1 AM THE LEGAL OWN
ER OF THE ABOVE DESCRIBED_RESIDENTIAL PROPERTY BACKFILL SEPTIC TANKS
SIGNATURE , /f SEEP PITS)❑ CESSPOOLS
OF PERMITTEE'
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