HomeMy Public PortalAbout5749 AGNES AVE_Sewer__ E 6D
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APPLICA TION FOR PERMIT 1
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DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Department of County Engineer
County of LOB Angeles BUILDING
WM J FOX COUNTY ENGINEER ADDRESS
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CASSATT D GRIFFIN SUP T OF BUILDING LOCALITY t
FOR APPLICANT TO FILL IN NEAREST I
CROSS ST
LEGALF /f �
DESCRIPTION LOT NO %� tel' OWNERMAIL
BLOCK TRACT ADDRESS 'co
ANO OF BLDGS
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SIZE OF LOT /
ANO
ON LOT CITY +�.i� ` L N
USE OF [[
BUILDINGS /L. I DISTRICTT N GRO P I MAP
CONTRACTOR �j �i 1/ ' �
]
ADDRESS CONNECTION DATA L
CITY TEL NO ff STATION 3 DEPTH
0 I El MANHOLE REFERENCE l T UPPER
REGISTRATION NO f{_A ❑ COUNIY /
NO DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO M TYPE ECTION LENGTH FROM -^� /
PUBLIC SEWER @ $ 3 50 CURB gy M L TO P L —y
hOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 100
CONNECT ADDITIONAL BLDG ORP
P C NO
WORK TO HOUSE SEWER 1 00 _CO IMP NO � {.J (� JOB NO
ALTER OR REPAIR EXISTING t
SEWER OR DISPOSAL SYSTEM 1 00 TRUNK PEPMIT NO ROAD PERMIT NO /,�I6 3 7
DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT
AND/OR DISPOSAL SYSTEM 1 00 PERMIT NO
SEPTIC TANY SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 00 INDUSTRIAL
CESSPOOL DRYWELL WASTE APPROIAL
SPECIAL CONDITIONS ONLY 2 00 CHARGES
CONNECTION CHARGE FEE
OWNER S PERMIT $ 1 00
AUTHORIZATION I TOTAL FEE 45
O REIMBURSEMENT FEE
TRACTORHAVE TTOS CONNECT THE DATE ABOVECTED WDESCR BED EXIISTINITH THE HEREIN IG DWELLING CON APPROVALS DATE INSPECTOR SSIGNATURE
TO ThE PUBLIC SEWER
SIGNED THIS-DAY OF f✓ Z Ig Q/O NEW HOUSE SEWER Cn A C
�� /� `/ � CONNECT ADDITIONALOWNER OR
�o
OWNERS AGENT '� 2' /C� / BUILDING OR WORK
�L.—A SEPTIC TANK SEEP PIT(S)
ADDRESS
— !t ' 4?n � +� ` AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAV READ THIS APPLICATION CESSPOOL[IDRYWELL[IAND 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
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE ABANDON HOUSE SEWER
DESCRIBED RESIDENTIAL PROPERTY .' BACKFILL SEPTIC TANKS❑ ffpp))
SEEP PIT(S)
❑ CESSPOOLS
SIGNATURE
C PERMITTEE
WILLIAM J FOX COUNTY ENGINEER VALIDATION R A WOOD CHIEF PLBG INSPECTOR
t kCO 6 6 6 4A Jum 4 450 In
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