HomeMy Public PortalAbout5937 AGNES AVE_Sewer_11/9/1964_ CE808 I
76A642D 0 63 APPLICATION FOR PER IT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILD'NG 7 A(5,v ef
r
JOHN A LAMBLE County Engineer A ..E'S
WILLIAM A JENSEN Supt of Building
LOCAL TY
NEAREST
CROSS ST
FOR APPLICANT TO FILL IN
LEGAL
DESC RIPTION LOT NO OWNER
MAIL
BLOCK TRACT ADDRESS
NO OF BLDGS CITY TEL NO
SIZE OF LOT NOW ON LOT I
USE 0 F DISTRICT NO ROU MAP PROCESSED BY
-BUILDINGS-...-- PI BK PG
CONTRACTOR
4VV,4 a.Z1 6,Y
ADDRESS A5�,7,3
CONNECTION DATA V
CITY IFY W"7eTEL NO(:*/ &'AAe7 STAT ON D EPTH
H STATE MANHOLE REIERENCE 41
REGISTRATION NO 1.7- IFT-7,57 COUNT 5 100k I
NO DESCRIPTION OF WORK FEE TYPE C,Fe;��10 N LENGTH FROM
HOUSE SEWER CONNECTING TO Y P L ML TOPIL
PUBLTC SEWER - @_S5 Do PC NO
SEPTiCTANK SEEPAGEPIT OR CO IMP NO JOB NO 0
PITS AND/OR DRAINFIELD @ 51000 U
0
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT No
PRIVATE DISPOSAL SYSTEM $3 00
CONNECT ADDITIONAL BLDG OR AJ�E�ECORD INSTR NO DATE
WORK TO HOUSE SEWER @ $300 eve
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL MANHOLE @ $500
HWY OR ST WIDENING
ALTER REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM @ $3 00 _.— STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
OVvrNER S PERMIT 21 00 WASTE APPROVAL CHARGES
AUTHORIZATION TOTAL FEE 1110,1 CONNECTION CHARGE FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTOR T 0 CO NNECT THE ABOVE DESCRIBED EX-ISTING DWELLING
TO T H E PUSL IC S EWER APPROVALS DtTE INSPECTOR S SIGNATURE
SIGNED THIS—DAY OF _19—
OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL
ADDRESS BUILDINGORWORK _ i
SEPTIC TANK SEEP PIT(S)
I HFREIIY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AN. STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WIT H ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEW C IRS CESSPOOL [:1 DRYWELL
1 HEREBY CERTIFY THAT I AM PROPERLY REGI STEREO AND/OR ALTER REPAIR SEWER OR
LICENSED AS REQUIRED By L OS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CAL�FORN I A OR THAT El A M TH E LEGAL OWNER OF/A No [0 DISCONNECT PLUG AND
LLRES DE IN THE ABOV DESCRIBED RESIDENTIAL PR E T ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS El
OF PERM
ITTEE SEEP PIT(S) El CESSPOOLS V5�,�t
VALIDATIO.N--\ ROBERT A WOOD
SUPERVISING MECHANICAL ENGINEER
CK M 0 Ls.1)
LA�o 5 6 9 5,,-' 0V 9 1 0 D 1300-
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