HomeMy Public PortalAbout5218 AGNES AVE_Sewer_12/30/1977_connect addtl work to house sewer I 4
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COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDINGS
ADDRESS
1
I
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROss ST
LEGAL
DESCRIPTION LOT NO OWNER
MAIL
BLOCK TRACT 2 G.� ADDRESS
—'
USE OF
BUILDINGS DISTRICT NO GROUP MAP PROC SSED BY
-elBK P
CONTRACTOR
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ADDRESS q CONNECTION DATA
CITY TEL NO 3 STATION DEPTH
STATE LIC UPPER
LICENSE NO /D (p CLASS �-- MANHOLE REFERENCE LOWER
NO I DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y CURB P L M L TO P L
PUBLIC SEWER C NO
IL
SEPTIC TANK SEEPAGE JOB NO PIT OR
PITS AND/OR DRAINFIELD CO IMP NO 0
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO
PRIVATE DISPOSAL SYSTEM
CONNECT ADDITIONAL Bt"- -- ^\ AFFIDAVIT I WAIV[11 lAlIM14T RECORD INSTR NO DATE 0
WORK TO HOUSE SEWER @ V 0
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL MANHOLE
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING 1 O.
SEWER OR DISPOSAL SYSTEM @ h
STATE ENCROACHMENT Z
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT $ CHARGES
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL 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 OR NEW HOUSE SEWER
OWNERS AGENT
CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION SEPTIC TANK SEEP PIT(S)
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY AND/OR DRAINFIELD
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT I 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 WNER OF AND INTEND TO DISCONNECT PLUG AND
RESIDE IN THE ABOVE DESCRIBED RE D NTIAL PR PERTY ABANDON HOUSE SEWER
SIGNATURE
OF PERMITTEE BACKFILL SEPTIC TANKS ❑
❑
EP PIT(S) ❑ CESSPOOLS
�VALIDATION
�ClC._/ M 0 CASH
91 0 EZbEG -')Olt-,) U 9 ❑ 0 ®.-,:,