HomeMy Public PortalAbout5837 AGNES AVE_Sewer__ 1
76A64 2D 0 63 APPLICATION FOR PER IT
A64
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION 7OWNER
JOHN A LAMBIE County Engineer
WILLIAM A JENSEN Sup t of Building
FOR APPLICANT TO FILL IN LEGAL DESCRIPTION LOT NO
MAIL D
BLOCK TRA ADDRESS a
NO OF BLDGS
SIZE OF LOT NOW ON LOT CITY TEL
USE OF DISTRICT NO GROUP MAP W11 BYBUILDINGSBK PGrAl �-�V
CONTRACTOR
ADDRESS CONNECTION DATA
CITY TEL NO w� STATION DEPTH `
STATE MANHOLE REFERENCE
REGISTRATION NO COUNTY ( LOWER
NO DESCRIPTION OF WORK F E TYPE OF CO I N LENGTH F OM ,e
HOUSE SEWER CONNECTING TO Y CURB P L M L TO
PUBLIC SEWER @ E3 00 PC NO a
SEPTIC TANK SEEPAGE PIT OR CO IMP NO JOB NO O
PITS AND/OR DRAINFIELD @ SIO 00 V
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT
PRIVATE DISPOSAL SYSTEM @ $300 Of
CONNECT ADDITIONAL BLDG OR AFFIDAVIT WAIVER EASEMENT RECORD INSTR N DATE V
WORK TO HOUSE SEWER @ $300
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL MANHOLE @ S5 00 a
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING N
SEWER OR DISPOSAL SYSTEM @ 33 00 S1ATE ENCROACHMENT Z
PCRMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT $ z o0
AUTHORIZATION TOTAL FEE 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 INSPECTOR S SIGNATURfi
SIGNED THIS DAY OF 19_ //II
OWNER OR NEW HOUSE SEWER I-y
OWNERS AGENT
CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS SEPTIC TANK SEEP PIT(S)
IH
ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
LRESIDE
COUNTY ORDINANCES AND STATE LAWS REGULATING
AND SEWERS CESSPOOL ❑ DRYWELL ❑
Y CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
IA OR THAT I AM THE LEGAL OWNER OF AND INTEND TO DISCONNECT PLUG AND
THE ABOVE D FD RESIDENTIAL PROPERTY ABANDON HOUSE SEWER
E SITTEE BACKFILL SEPTIC TANKS ❑ w
SEEP PIT(S) ❑ CESSPOOLS �6r
----VALIDATION ROBERT A WOOD
SUPERVISING MECHANICAL ENGINEER
CK M O CASH
L_ IvG 8 3 u 7 ti' FEB 8 1 0 D 7 ci 0-