HomeMy Public PortalAbout5128 AGNES AVE_Sewer_3/11/1964_house sewer connection to public sewer TEMPLE CITY
1
76A64 2D 0 63 APPLICATION FOR PERMIT
A64 �J
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDI7NG
JOHN A LAMBIE County Engineer ADDRE �I
9 N. Agnes Ave
WILLIAM A JENSEN Sup t of Building 1 City
LOCALNEAREFOR APPLICANT TO FILL IN CROSS Rosa
LEGAL �1'`•
DESCRIPTION LOT N❑A� OWNEREtherton
�� / MAIL
BLOCK TRACT (bV• ADDRESS
NO OF BLDGS (l
SIZE OF LOT NOW ON LOT CITY Temple Clt TEL NO
USE OF
BUILDINGS DISTRICT NO GR MAP PROCESSED BY
° J n BK PG
CONTRACTORSquare Deal Sewer Service -5, _ (�
ADDRESS2933 Maxson Rd . CONNECTION DATA
CITY me TEL NO GI _2020 STATION l DEPTH
STATE !'�✓ ATM�
REGISTRATION NO ® COUNTY MANHOLE REFERENCE x OWER
NO DESCRIPTION OF WOfRK FEETYPE OF CONNECTION LEND H FRO
1 HOUSE SEWER SEW ER CONNECTING TO $S 00 00 Y CURB P L ML TO P LPUBLIC a
SEPTIC TANK SEEPAGE PIT OR D L'^'� P C NO O
PITS ANO/OR DRAINFIELD @ S1000 CO IMP NO /3 "5
JOB NO
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO L/ pC
PRIVATE DISPOSAL SYSTEM @ $3 00 / f'1
CONNECT ADDITIONAL BLDG OR AFFIDAVIT WAIVEN EASEMEN7 RECORD INSTR NO DATE V`
WORK TO HOUSE SEWER @ S3 00 iV•
OVERFLOW SEEPAGE PIT DRAINFIELD lIJ
E XTN CESSPOOL DRYWELL MANHOLE @ SS 00 d
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING N
SEWER OR DISPOSAL SYSTEM @ 3300 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT $ 2 00
AUTHORIZATION TOTAL FEE 7
00 CONNECTION CHARGE FEE
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS
TO THE PUBLIC SEWER D TE INSPECTORS SIGNATURE
SIGNED THIS DAY OF 19_ L
OWNER OR NEW HOUSE SEWER r
OWNERS AGENT
CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
SEPTIC TANK SEEP PIT(5)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
IHEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
LICENSEDAS 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
LS
LNAT.
THE ABOVE DESCRIBED RESIDE IAL PROPERTY ABANDON HOUSE SEWER
BACKFILL SEPTIC TANKS ❑
ITTEE VVV"` ❑
SEEP PIT(S) ❑ CESSPOOLS
VALIDATION ROBERT A woos
SUPERVISING MECHANICAL ENGINEER
CK M O CASH
LAAO 6 4 8 51 i u1R 11 1 0 D 700-