HomeMy Public PortalAbout5931 AGNES AVE_Sewer_10/7/1959_ CE808a sa APPLICATION FOR PERMIT 1
canoe a COUNTY OF LOS ANGELES
SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING ,/yAV
JOHN A LAMBIE County Engineer ADDRESS ��
CASSATT D GRIFFIN Sup t of Building LOCALITY a1, ack?aIx b"/T Dt1
NEAREST
FOR APPLICANT TO FILL IN _caoss sT ,
LEGAL p�j J� �j S
DESCRIPTION LOT NO OWNER [V 1 f � !�S �^�
BLOCK TRACT MAIL
ADDRESS
SIZE OF LOT NOW ON LOTS CITY_ ` SEL'NO
USE OF
BUILDINGS -A? N/d jr7, DISTRICT NO GROUP MAP / PROCESSED BY
CONTRACTOR
ADDRESS �� u `T CONNECTION DATA
CITY E STATION t ,_S-DEPTH
® STATE MANHOLE REFERENCE � U
REGISTRATION N COUNTY 7(J LOWER
No DESCRIPTION ON F WaRK v FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3 00
SEPTIC TANK SEEPAGE PIT OR TYPE OF ION LENGTH FROMY RB P L M L TO P L /
PITS AND/OR DRAINFIELD @ $3 00
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL MANHOLE @ $2 00
HOUSE SEWER CONNECTING TO P C NO
PRIVATE DISPOSAL SYSTEM @ $1 00 CO IMP NO JOB No
CONNECT ADDITIONAL BLDG OR TRUNK PERMIT NO ROAD PERMIT NO
WORK TO HOUSE SEWER @ $1 00
ALTER REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
SEWER OR DISPOSAL SYSTEM @ $1 00 PERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNER S PERIM $ 2 00 CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEEREIMBURSEMENT FEE
R
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON APPROVALS DATE INSPECTOR S SIGNATURE
TACTOR TO CONNECT THE ABOVE DESCRIBED XISTING DWELLING
TO THE PUBLIC SE R (y p
SIGNED THIS AY OF Ig� NEW HOUSE SEWER _ y q p
OWNER OR ,f''' CONNECT ADDITIONAL
31 a�o
OWNERS AGENT 1 � - BUILDING OR WORK
�C' tf ,. SEPTIC TANK SEEP PIT(S)
ADDRESS AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT PHAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL❑ DRY-WELL❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
1HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIAL PROPERTY BACKFILL SEPTIC TANKS❑ ✓ /
SIGNATURE SEEP PITS ❑ CESSPOOLS
OF PERMITTEE_
®F VALIDATION ROBERT A WOOD
td
� p �gR SUPERVISING MECHANICAL ENGINEER
LACD 3 G 8 2u'-- OCT 7 1 0 A 5 00 tn
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