HomeMy Public PortalAbout5928 AGNES AVE_Sewer_2/4/1977_ 76A 642D - CE608 - 9/73 APPLICATIO FOR PER
T ,� ��5�
COUNTY OF LOS ANGELES SEWER- WAGE DI OSAL
76A 642D - CE808 - 9/73
APPLI�
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST
LEGAL
DESCRIPTION LOT NO OWNER
/J MAIL
BLOCK TRACT ��/ ADORE
NO OF BLDGS
SIZE OF LOT NOW ON LOT CITY TEL NO
USE OF DISTRICT NO GROUP MAP ESSED BY
BUILDINGS BK P
CO ` �-do 1 / 2 b
i CONNECTION DATADDR ss STATION DEPTH
CITY TEL O 3 713s,-_r
LICENSE NO CLASS MANHOLE REFERENCE � Al ,�q ?' LOWER
NO DESCMPT O F WORK FEE TYPE OF CONNECTI LENGTH FROM
HOUSE SEWER CONNECTING TO /� Y CURB ML TOP L
PUBLIC SEWER ! $700 U PC NO
SEPTIC TANK SEEPAGE PIT OR
PITS AND/OR DRAINFIELD Q $1000 CO IMP NO JOB NO /�
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO ,,l
PRIVATE DISPOSAL SYSTEM S300 V
CONNECT ADDITIONAL BLDG OR AFFIDAVIT I WAIVER I [AS[M[MT RECORD INSTR NO DATE
WORK TO HOUSE SEWER ® 5300-
OVERFLOW SEEPAGE PIT DRAINFIELD O
EXTN CESSPOOL DRYWELL $500 V
HWY OR ST WIDENING
ALTER REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM $300 STATE ENCROACHMENT O
MANHOLE $7 00 PERMIT NO L5
W
INDUSTRIAL a
��+ WASTE APPR A Z
610
O{_MER S PERMIT s �1 CHARGES
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXIST G DWELLING
TO THE PUBLIC SEWER APPROVALS DATE INSPECTOR S SIGNATURE
SIGNED THIS F 19_
OWNER OR NEW HOUSE SEWER /
OWNERS AGENT
CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
SEPTIC TANK SEEP PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION PND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL Cl DRYWELL ❑
1 HEREBY CERTIFY THAT I AM PROPERLY REGIS. ERED AND/OR ALTER REPAIR SEWER OR
LICENSED AS REQUIRED BY LOS ANG COU ND STATE OF SEWAGE DISPOSAL SYSTEM
CA LIFCFNIA R THAT I AM THE LEG NER F NO INTEND TO DISCONNECT PLUG AND
RESIDE IN TH OVE DESCRIBED ENT L P PERTY ABANDON HOUSE SEWER
SIOF PE BACKFILL SEPTIC TANKS Cl
OF PE TTTE ✓
SEEP PITIS) ❑ CESSPOOLS ❑
VALIDATION CK M 0 CASH
409'r--rEB 110 U 1 500
Q vv
0 � _
76A 6420 — CE808 — 9/73 APPLIC TION FOR PER IT q ,
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOS L
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING _ `'�v
ADDRESS
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROss Sf
LEGAL
DESCRIPTION LOT NO OWNER
MAIL
BLOCK TRACT6 -5-01
ADDRES
NO OF SLD"
SIZE OF LOT NOW ON LOT CITY —_ TEL NO
USE OF
BUILDINGS 1 DISTRICTNO GROUP BK p MAP L2:z�
Q
CONT R TO O `L 1-4y
ADDRESS (/ CONNECTION DATA
CITY TEL NO r STATION � 93( E`er DEPTH
ST E LIC MANHOLE REFERENCE +off ��w Q a/ v
LICENSE NO CLASS 3—y'`� 7,7 LOWER
NO I DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y CURB P L ML TOPIL
PUBLIC SEWER @ $7 00
SEPTIC TANK SEEPAGE PIT OR PC NO
PITS AND/OR DRAINFIELD ® $1000 CO IMP NO JOB NO
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO /
PRIVATE DISPOSAL SYSTEM @ $300
CONNECT ADDITIONAL BLDG OR AFFIDAVIT WAIVER [AIININI RECORD INSTR NO DATE
WORK 70 HOUSE SEWER a $300 p�
OVERFLOW SEEPAGE PIT DRAINFIELD U
EXTN CESSPOOL DRYWELL $500 ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING
SEWER OR DISPOSAL SYSTEM $300 STATE ENCROACHMENT O�
MANHO a7 00 PERMIT NO W
INDUSTRIAL CL
WASTE APPROVAL N
Z
CHARGES
OS'NER S PERMrr s
AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN AMED CON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED XIS NG DWELLING APPROVALS
TO THE PUBLIC SEWER DATE INSPECTOR S SIGNATURE
.�
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
SEPTIC TANK SEEP PIT(S) ff
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD o
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING r
97
CIDE
AND SEWERS CESSPOOL ❑ DRYWELL ❑
Y CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
AS REOUIRED BY LOS ANGL S C UNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
R THAT I AM 7 E LEGA OWN R OF AND INTEND TO DISCONNECT PLUG AND
T E ABOVE DE IBED ESID IAL P PERTY ABANDON HOUSE SEWER
OF PERMITTEE 1 BACKFILL SEPTIC TANKS ❑
SEEP PIT(S) ❑ CESSPOOLS ❑
VALIDATION CK M O CASH
4 1 0 FEB 1 1 1 0 3 0 o o A��