HomeMy Public PortalAbout5923 AGNES AVE_Sewer_6/22/1966_ 76608565
76A642D APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A I A%BH County F ngmeer ADDRESS
COU PIAN VV JFNLINS Sup t of Building
LOCAL TY
NEAREST
FOR APPLICAN�,TO FILL IN CROSS ST
LEGAL
DESCRIPTION LOT NO OWNER
MAIL ��
BLOCK TRACT ADDRESS
NO OF BLDGS �✓
SIZE OF LOT NOW ON LOT CITY EL NO
USE OF DISTRICT NO OUP MAP PROCES BY
BUILDINGS
(/ BK PG
CONTRACTOR „�, J 0,, A5-/2
ADDRES CONNECTION DATA
CITY TEL NO STATION DEPTH
CE NSE /1 CLA SsLICEN — UPPER
NO
v( MANHOLE REFERENCE
LOWER
NO DES CRIP ION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y CURB P L TOP L
PUBLIC SEWER C $ 5 00 >.
PTIC TANK SEEPAGE PIT OR PC NO d
PITS AND/OR DRAI NFIELD C $10 00 CO IMP NO JOB NO O
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PER-I NO V
PRIVATE DISPOSAL SYSTEM C $ 3 00
CONNECT ADDITIONAL BLDG OR AFFIDAVIT 1 * EASEMENT RECORD INSTR NO DATE O
WORK TO HOUSE SEWER C $ 3 00
'ALTERREPAIR R ABANDON HOUSE (,J
SEWER OR DISPOSAL SVSTFM C $ 3 CO W
--CYVERFE OWHWY OR S WIDENING N
EXTN CESSPOOL MANI OLE C $ 5 00 STATE E ROACHMENT Z
PERCOLATION TEST C $ 5 OG PERMIT O
INDUS IAL
WAST APPROVAL
1^ CHARGES
OWNER S PERMIT $1
hoz 00
AUTHORIZATION TOTAL FEE -^ CONNECTION CHARGE FEE
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTOR TOCONNECT 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
I HFREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION SEPTIC TANK SEEP PITS)
AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING CESSPOOL ElDRYWELL [:1 '
PLUMBING AND SEWERS
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR T T I A HE LEGAL OWNER OF AND INTEND TO DISCONNECT PLUG AND
RESIDE IN THE AB VE ES IBED RESIDEY ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMITTEE SEEP PIT(S) ❑ CESSPOOLS ❑
VALIDATION
CK M O CASH
Lko300 ?1-51 JU12210 D 500- Q
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