HomeMy Public PortalAbout5817 AGNES AVE_Sewer_9/20/1974_ r �+ d
r LI
76A 642D-CE808-1071 APPL,,ICATION R PERMIT '
COUNTY OF LOS ANGELES SEWER— W �`DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING a�
ADDRESS
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST
LEGAL U /._ '
DESCRIPTION LOT NO ( OWNER ///YYY Fr
MAIL
BLOCK TRACT `j^ ADDRESS ` A)Fs at
NO OF BLDGS
SIZE OF LOT NOW ON LOT CITY EL NO
rF
USE OF [� DISTRICT NO ROUP MAP SED BY
BUILDINGS C
�,�r-� {� T SK / P
CONTRACTOR ` I F E ^ U��$ y �'
ADD Ess p O > V CONNECTION DATA
STATION /,2 DEPTH
TEL NO 00
SVTATE 0'
UPPER
LICENSE NO a f CLASS �, MANHOLE RE FERE NCE�1n v ��7�5' DO 6DiW&R
NO DESCRIPTION OF WORK FEE TYPE OF CO TION LENGTH FROM
/ HOUSE SEWER CONNECTING TO Y URB P L M L TOP L
PUBLIC SEWER @ $7 00 D O P C NO
SEPTIC IANK SEEPAGE PIT OR CO IMP I Q JOB NO
PITS AND/OR DRAINFIELD 0 $1000
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO / il.
PRIVATE DISPOSAL SYSTEM E3 00 O
CONNECT ADDITIONAL BLDG OR AFFIDAVIT WAIVIII [AS[M[NT RECORD INSTR NO DATE V
WORK TO HOUSE SEWER @ $3 00
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL @ $500 O
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING F,
SEWER OR DISPOSAL SYSTEM $3 00 STATE ENCROACHME T W
MANHOLE PERMIT NO
$7 00
INDUSTRIAL NZ
WASTE APPROVAL
OWNER S PERMIT S 3 00 CHARGES
AUTHORIZATION I TOTAL FEE �0 O CONNECTION CHARGE 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 INSPE TOR SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR 1 NEW HOUSE SEWER n
OWNERS AGENT - 6' CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
SEPTIC TANKSEEP PIT(S)
I HEREBY ACKNOWLEDGE THAT HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL 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
LICENSED AS REOU BNSANGLIESLROF
AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR TH T I MOW AND INTEND TO DISCONNECT PLUG AND
RESIDE IN THE A OVE EIDPROPERTY ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ElOF PERMITTEE
SEEP PIT(S)/Z CESSPOOLS El U
ki VALIDATION CK M 0 CASH
z
0 2 3 r SEP 1�U 1 0 0 1 CJ.0 0 ,&-3b