HomeMy Public PortalAbout5226 AGNES AVE_Sewer_1/22/1958_house sewer connection to public sewer E 6D
S& 83 11 SS FOR O E PERMIT
8 E 8
DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Department of County Engmeer
County of Los Angeles BUILDING /]
JOHN A LAMBIE COUNTY ENGINEER ADDRESS
® CASSATT D GRIFFIN SUP T OF BUILDING LOCALITY
FOR APPLICANT TO FILL IN CROSS STLEGAL
'
DESCRIPTION LOT NO q��Sp
OWNER
f
BLOCK TRACT MAIL`/ (� ( ADDR SS
NO OF BLDGS
SIZE OF LOT NOW ON LOT CI
USE OF
BUILDINGS DISTRICT k
0 G OUP MAP
BK PG'
CONTRACTOR � � 4=�
ADDRESS CONNECTION DATA
CITY TEL NO STATION `Y -7'-3S DEPTH '
` yyy MANHOLE REFERENCEi UPPER
y�� ❑ STATE +� LOWER
REGISTRATION NO ❑ COUNTY
No DESCRIPTION OF WORK FE
HOUSE SEWER CONNECTING TO TYPE OF CONNE ION LENGTH FROM
PUBLIC SEWER
@ $350 Y CURB PL M L TOPL
SEPTIC TANK SEEPAGE PIT OR
PITS AND/OR DRAINFIELD Q $3 00 �`w
OVERFLOW SEEPAGE PIT DRAINFIELD CO IMP NO �0�+ 10B N00
EXTN CESSPOOL DRYWELL MANHOLE Q $2 00
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM Q $1 00 _TRUNK PERMIT NO ROAD PERMIT NO /
CONNECT ADDITIONAL BLDG OR ,/� STATE ENCROACHMENT
WORK TO HOUSE SEWER @ $1 00 eo- PERMIT NO
ALTER REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM Q $1 00 WASTEAPP RC,V
06 F
C CHARGES n
CO NECTION CHARGE FEE
OWNER S PERMIT S 1 00
a
REIMBURSEMENT FEE
AUTHORIZATION TOTAL FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON APPROVALS DATE INSPECTOR SSIGNAT RE
TRACTOR TO CONNECT THE ABOVE DE5Z.41BED EXISTING DWELLING
TO THE PUBLIC SE E er—C, NEW HOUSE SEWER
SIGNED THIS DAY OF lfZ CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK
OWNERS AGENT SEPTICTANK SEEP PIT(S)
ADDRESS AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
1HEREBY CERTIFY THAT 1 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 OF THE ABOVE
DESCRIBED RESIDENTIA OPERTY /� BACKFILL SEPTIC TANKS❑
SIGNATURE / ft, SEEP PIT(S) ❑ CESSPOOLS( d
OF PERMITTEE ;Z ! , -I �d
JOHN A LAMBIE COUNT{ENGINEER VALIDATIO ROBERT A WOOD CHIEF PLBG INSPECTOR
CK i
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