HomeMy Public PortalAbout5812 AGNES AVE_Sewer_12/8/1955_ 7SA6420 APPLICATION T'IOiii FOR ■PERMIT
S C,11 683 3 SS
? DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL
Department of County Engineer o
County of LOS Angeles pU LD1,NG `
WM J FOX COUNTY ENGINEER r
CASSATT D GRIFFIN SUP T OF BUILDING LOCALITY n L (y
LEGAL FOR APPLICANT TO FILL IN NEAREST--P _ /
CROSS F
DESCRIPTION LOT NO &. S'0/,5P= OWNER
BLOCK TRACT ® _ADDRESS
NO OF BLDGS
SIZE OF LOT ® /� O NOW ON LOT CITY ,,,FamAl TEL NO
USE OF �,q� _
BUILDINGS DISTRICT NO GROUP MAP
CONTRACTOR ^ ' ,�. / SKPGI
ADDRESS CCONNEcC:ST•ION DATA
Cir ,rft,j( .AnC TEL N0�`` l� r STATION f-0ems DEPTH 6�
I-STATE MANHOLE REFERENCE �°� �®u UPPER
REGISTRATION NO ❑ COUNTY a
NO DESCRIPTION OF WORK FEE _
A HOUSE SEWER CONNECTING TO TYPE ONECTION LENGTH FROM �
4- PUBLIC SEWER Qa $ 3 50 Y (CURB) P L M LTO P L
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 100 _
CONNECT ADDITIONAL BLDG OR P C NO
_ WORK TO HOUSE SEWER 1 00 CO IMP NO 12)C6JOB NO
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SISTEM 1 00 TRUNK PERMIT NO ROAD PERMIT NO
DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT
AND/OR DISPOSAL SYSTEM 1 00 PERMIT NO
SEPTIC TANK SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 2 00 INDUSTRIAL
CESSPOOL DRYWELL WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2 00 CHARGES
$ t o0
OWNERS
PERMIT CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
IHAVE N N(MED CON
TRACTORTO DATE CONNECT THE ABODVEWITH THE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPEC(OR S SIGNATURE
TO THE PUBLIC SEWER
SIGNED THIS NEW 14OUSE SEWER
DAY OF 19_ ,
OWNER A CONNECT ADDITIONAL
OWNERS AGENT ,1,' yk(L' BUILDING OR WORK
SEPTIC TANK SEEP PIT(S)
ADDRESS AND/OR DRAINFIELD
1 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
PLUMBING AND SEWERS ALTER REPAIR SEWER OR
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR SEWAGE DISPOSAL SYSTEM
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF THE ABO6E ABANDON HOUSE SEWER
DESCRIBED RESIDENTIAL PROPERTY BACKFILL SEPTIC TANKS C
SIGNATURE /�T �y��� SEEP PIT(S) ❑ CESSPOOLS❑
OF PERMITTf
WILLIAM J FOX COUNTY ENGINEER VALIDATION R A WOOD CHIEF PLBG INSPECTOR
LCOO 6 7 64n DEC 8 4 4..5 0 In
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