HomeMy Public PortalAbout5803 AGNES AVE_Sewer__ DEPAUf ENT OF COUNTY ENGINIM i SEWER—SEWAGE DISPOSAL
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
WILLIAM J FOX, COUNTY EN13INEER I BUILDING
ADDRESS
FOR APPLICANT TO-FILL IN LCCALITY
BUILDINGNEAREST 4
ADDRESS s(JD CROSS ST GalZ.1/E'.C� G / _
LOCALITY DISTRICT NO SERIAL NO PERMIT NO
�-- A --- 3�6 7 S
NEAREST
CROSS ST
RECEIVY Ready for Inspection DATf ���
OWNER
MAIL olUS� OCCUPANCY .G6dGP�-
ADDRESS Q /yYLG/ _ I BK
CITYTEL NO 4'00
CONTRACTOI B n CO IMP NO
ADDRESS , JOB NO
CITY TEL NO/l 10 So TRUNK PERMIT NO
REGISTRATION NO COUNTY ROAD PERMIT NO
LEGL
a r
DESCRIPTION LOT NO STATE ENCROACHMENT -�
NO
i
BLOCK ___TRACT aINDUSTRIAL
WASTE APPROVAL
SIZE OF LOT SQL NO OF BLr
O A NOW ON LOTT / � CHARGESUSOF
y
BUE DING RJ_Q 161 CONNECTION CHARGE FE
NO DESCRIPTION OF WORK FEE
REIMBURSEMENT FEE
HOUSE SEWER CONNECTING TO /
N PUBLIC SEWER @ $ 350 3 15Df RECEIPT NO !ATE BY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1 00
CONNECT ADDITIONAL BLDG OR EXCEPTION RE HOED
_ WORK TO HOUSE SEWER 1 00 2— CQD
ALTER OR REPAIR EXISTING / NO DATE I BY
_SEWER OR DISPOSAL SYSTEM 100 /
DISCONNECT AND ABANDON SEWER -
AND/OR DISPOSAL SYSTEM 1 00 CONNECTION DATA
SEPTIC TANK SEEPAGE PIT OR �f
PITS AND/OR DRAINFIELD 200 STATION , ��/S DEPTH
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 2009
00 /��G/�y / MANHOLE REFERENCE
� V CLCE13r- LOWER
TYPE OF NNFCTION LENGTH FROM
GXYm CURB .e�E M L TOP L
OWNERS PERMIT 1 " , oo ozr����v/�. �>
AUTHORIZATION TOTAL FEE '7 Q
IHAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED e,--'0/v/4 (:P/,/
CONTRACTOR TO CONNECT THE ABOVE DESCRIB D EXIbTING APPROVALS INSPECTOR S SIGNATURE DATE
DWELLING TO THE PUBLIC SEWE
SIGNED THIS-Z7 DAY OF NEW HOUSE SEWER &4 r6 e-
OWNER 0 CONNECT ADDITIONAL
OWNERS AGENT _ _ _ _ BUILDING OR WORK
.�- SEPTIC TANK SEEP PIT(S)
ADDRESS _ - AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLI CESSPOOL❑ DRYWELL
CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER REPAIR SEWER OR
REGULATING PLUMB NG AND SEWERS SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED DISCONNECT PLUG AND
AWD/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 DESCRIBED RESIDENTIAL PROPERTY BACKFI LL SEPTJCTANKS
SIGNATURE
%/V �� SEEP PIESSPOOLS 0
OF PERMITTEE �� -
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