HomeMy Public PortalAbout5822 AGNES AVE_Sewer_5/23/1960_house sewer connection to public sewer 3 64
76A64 2D APPLICATION FOR PERMIT
6A64 �J
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A LAMBIE County Engineer ADDRESS Z, a.
WILLIAM A JENSEN Sup t of Building
LOCAL TY
NEAREST
FOR APPLIC T TO FILL IN `ROSS ST
LEGAL /
DESCRIPTION LOT NO /OWNER
MAIL
BLOCK TRACT ADDRESS
NO OF BLOGS /
SIZE OF LOT NOW ON LOT CITY TEL NO
USE OF DISTRICT NO GROUP MAP &�ESSEDCBY
BUILDINGS BK PG
CONTRACTO
ADDRESS ,, — ¢-d0 CONNECTION DATA
STATION ��{� DEPTH
CITY TEL NO
// STATE MANHOLE REFERENCE n ` UPPE
REGISTRATION NO (� COUNTY {'!� ) , �/ LO ER
NO DESCRIPTION OF WORK FE TYPE OF C2AW5C.,TIONNITIFO"
HOUSE SEWER CONNECTING TO Y CURB P L M L TOP L
PUBLIC SEWER @ $5 00 PC NO
SEPTIC TANK SEEPAGE PIT OR CO IMP NO D6 JOB NO a
PITS AND/OR DRAINFIELD @ 51000 Q
HOU 5E SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO U
PRIVATE DISPOSAL SYSTEM @ 43 00gT�j
ad
CONNECT ADDITIONAL BLDG OR AFFIDAVIT I WAIVES I EASEMENT RECORD INSTR NO DATE
WORK TO HOUSE SEWER @ $300 O
`y ,
OVERFLOW SEEPAGE PIT DRAINFIELD V
EXTN CESSPOOL DRYWELL MANHOLE® E5 00 W
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING d
SEWER OR DISPOSAL SYSTEM @ $300 STATE ENCROACHMENT yNy
PERMIT NO L
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNER S PERMIT s 2 00
AUTHORIZATION I TOTAL FEE CONNECTION CHARGE FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREINNAMED CON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER APPROVALS DATE INSPECTOR S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS SEPTIC TANKSEEP PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAI NFIELD
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 1 AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF AND INTEND TO DISCONNECT PLUG AND
RESIDE IN VE DESC IB
THE ED RESIDENT I L PROPERT ABANDON HOUSE SEWER
SIGNATURE „ /y BACKFILL SEPTIC TANKS ❑
OF PERMITTEE "�T CC�19.0 ❑
SEEP PIT(S) ❑ CESSPOOLS
VALIDATION ROBERT A WOOD
SUPERVISING MECHANICAL ENGINEER
CK M O CASH
LAL,04 7 9 9%-a 1w23 _ a D 7.00