HomeMy Public PortalAbout5838 AGNES AVE_Sewer__ 2/70
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642D APPLICATION FOR PERMIT
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COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL Ifl
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING /� Aet
JOHN A LAMBIE COUNTY ENGINEER ADDRESS VT-58 G' V
COLEMAN W JENKINS SUP T OF BUILDING
LOCALITY C/
NEAREST
FOR APPLICANT TO FILL IN caoss ST
(PRINT OR TYPE ONLY) '
LEGAL ) /
DESCRIPTION LOT NO �Q'F / OWNER /
/// MAIL
BLOCK TRACT VJ ADDRESSNO
SIZE OF LOT NOWOON LOTS CITY JTEL NO r99
.31-
11
USE OF [MAN
ICT GROUP CL SS MAP ED BY
BUILDINGS BK p
CONTRACTOR Y, Ite-
ADDRESS lJ CONNECTION DATA
CITY C/ TEL NO L /� ION DEPTH
STATE LIC HOLE REFER NC UPPER
LICENSE N CLASS LOWER
NO DESCRIPTION OF WORK FEE TYPE OF CONN ION LENGTH F M
HOUSE SEWER CONNECTING TO CURB P L M L TO P
PUBLIC SEWER $5 00 PC NO '-
SEPTIC TANK SEEPAGE PIT OR JOB NO
PITS AND/OR DRAINFIELD @ $1000 MP NO
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO R ERMIT NO d
PRIVATE DISPOSAL SYSTEM @ S300
CONNECT ADDITIONAL BLDG OR AFFIDAVIT w111YEE [As a MEMT RECO IN NO DATE O
$300 C , V
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL MANHOLE @ $5 00
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING O
SEWER OR DISPOSAL SYSTEM @ 5300 STATE ENCROACHMENT U
PERMIT NO
a
INDUSTRIAL N
WASTE APPROV Z
CHARGES
OWMER S-1 PERMIT s 00
AUTHORIZATION TOTAL FEE 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 APPROVALS
TO THE PUBLIC SEWER DATE INSPECTOR S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL
BUILDING OR WORK i0 `
ADDRESS SEPTIC TANK SEEP PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD 4
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING '� ❑ +'U
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
LICENSEDAS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM �r y
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF AND INTEND TO DISCONNECT PLUG AND
RESIDE IN THE ABOVE DESCRIBED RE5WIFNTIAL PROPERTY ABANDON HOUSE SEWER
SIGNATURE / U BACKFILL SEPTIC TANKS ❑
OF PERMITTEE '� O///�G_-_- SEEP PIT(S) ❑ CESSPOOLS ❑
VALIDA JACK R ALLEN
CK
SUPERVISING MECHANICAL ENGINEER
M CASH
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