HomeMy Public PortalAbout5136 AGNES AVE_Sewer_12/16/1953_house sewer connection to public sewer DEPARTMENT OF COUNTY ENI G)WEER SEWER—SEWAGE DISPOSAL
DIVISION OF BUILDING AND SAFETY + PERMIT APPLICATION
COUNTY OF LOS ANGELES
WILLIAM J FOX, COUNTY ENGINEER I BUILDING
ADDRESS r/35C
FOR APP CANT TO FILL IN LOCALITY
BUILDING �/ �� G ! NEAREST
ADDRESS 1� CROSS ST CY��
LOCALITY 6 DISTRICT NO SERIAL NO PERMIT NO C
NEAREST A S
CROSS ST /
REC_EIVED BY Ready for Inspection DATE ISSUED
OWNER L!/ I— �G19MAIL /fQJIi �,fa�/C` j � —' / 6 —�
ADDRESS �r/��� G���/9/_� USEZONE OCCUPANCY MAP
BK PG
�j
CITY /�1TEL.N0 ' A — I — �D
CONTRACTOR �/fj q/J CO IMP NO ' O S— Q
ADDRESS /�ao.rt� 7 JOB NO
CITY��hA�G TEL NO jj`/ TRUNK PERMIT NO
STATE
REGISTRATION NO �(f ✓�if 0 COUNTY ROAD PERMIT NO 3
LEGAL �y STATE ENCROACHMENT
DESCRIPTION LOT NO -/1 PERMIT NO
BLOCK TRACT ! INDUSTRIAL ^�
WASTE APPROVAL
SIZE OF LOT NO OF SLOGS
NOW ON LOT CHARGES
USE OF , /
BUILDINGS �y�(/ CONNECTION CHARG EE
NO DESCRIPTION OF WORK FEE
REIMBURSEMENT FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER 0 $ 350 t/6/ RECEIPT NO I / E BY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1 00
CONNECT ADDITIONAL BLDG OR NO I-EICEPTION RECORD
WORK TO HOUSE SEWER 1 00
ALTER OR REPAIR EXISTING DATE
SEWER OR DISPOSAL SYSTEM 1 00
DISCONNECT AND ABANDON SEWER f
AND/OR DISPOSAL SYSTEM 1 00 CONNECTION DATA
SEPTIC TANK SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 200 STATION Q-/- 5r DEPTH�' b
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 200 MANHOLE BREFERENCE
1 14LOWER
TYPE0 CTION LENGTH FRO
s>E� CURB =I M L TOPIL
OWNERS I r10 PERMIT ; I I oo
AUTHORIZATION TOTAL FEE I c( --u r- ('✓�\
1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR S SIGNATURE DATE
DWELLING TO THE DUBLIC SEWER
SIGNED THIS DAY OF -Q?-- _ 192— NEW HOUSE SEWER
£�1 _ _ CONNECT ADDITIONAL
OWNER OR
OWNERS AGGENT'^ _ � BUILDING OR WORK
ADDRESS j/"� ���� -q/ YP� SEPTIC TANK SEEP PIT(S)
AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI CESSPOOL[] DRYWELL
CAT
IONAND 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 IAM PROPERLY REGISTERED DISCONNECT PLUG AND
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOUSE SEWER
AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN
ER OF THE ABOVE DESCRIB RESIDENTIAL PROPERTY BACKFILL SEPTIC TANKS
SIGNATURE / ���� SEEP PIT(S)� CESSPOOLS
OF PERMITTEE 444CCC"` _
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