HomeMy Public PortalAbout5920 AGNES AVE_Sewer__ L
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6&E63 12 54 -APPLICATION FOR PERMIT
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DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL I,E�
Department of County Engmeer
County of Los Angeles BUILDING
WM J FOX COUNTY ENGINEER ADDRESS
CASSATT D GRIFFIN SUP T of BUILDING LOCALITY
FOR APPLICANT TO FILL IN NEAREST
CROSS ST
LEGAL L
DESCRIPTION LOT NO 7 / OWNE
BLOCK TRACT �/��// MAIL
.� e2 ADDRESS
NO OFBLDGS
SIZE OF LOT NOW ON LOT CITY A 40TEL NO
USE OF
BUILDINGS ADISTRIC NO GROUP MAP
CONTRACTOR I T— F- 126
ADDRESS / , CONNECTION DATA
CITY TEL NO STATION DEPTH
ATE MANHOLE REFERENCE
REGIS AT[ON ❑ COUNTY UPPER LOWER
4
TYPE OF CONNECTION LENGTH FROM
NO DESCRIPTION OF WOW FEE Y CURB P L M L TO P L
HOUSE SEWER CONNECTING TO
PUBLIC SEWER Q $ 3 50
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 100
CONNECT ADDITIONAL BLDG OR t CO IMP NO JOB 0
WORK 10 HOUSE SEWER 1 00
ALTER OR REPAIR EXISTING —Y-'+++ ""
SEWER OR DISPOSAL SYSTEM 1 00 TRUNK PERMIT NO X0 AD 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
C04NECT1 CHARGE FEE
OWNERS PERMIT 1 00
AUTHORIZATION TOTAL FEEREIM RSEMENT FEE
TRACTOR TTOSCONNECT THE AABOVECTED WDESCR BED EXESTI NpDWELLI G CON APPROVALS DATA INSPECTOR S SIGNATURE
TO THE PUBLIC SEWER
SIGNED THIS Z DAY OF 1 �� NEW HOUSE SEWER 3-$�55
OWNER OR ! CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
SEPTIC TANK SEEP PIT(S)
ADDRESS AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THA HAVE READ THI APPLICA CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO CO LY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS ALTER REPAIR SEWER OR
SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR HAT 1 AM THE L GAL OWNER TH A 0
DE IBED RESID NTIA RIP
BACKFILL`' ❑
TANKS n
SEEPPIT(s) El CESSP00LS
SIG ( 01 t
M
s
WILLIAM J FO NT NGINEER VALIDATION
BY 1'0 13'9-n PtR �. 4 2-0'0 �
DEPUTYr]„ �I_ __ � DEPUTY
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BY BY
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