HomeMy Public PortalAbout5951 AGNES AVE_Sewer_12/4/1964_ f C
75 642D� 63 APPL'ICATI N FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING r� / a
JOHN A LAMBIE County Engineer ADDRESS
WILLIAM A JENSEN Supt of Building
LOCAL TY �/ I
NEAREST
FOR APPLICANT TO FILL IN `ROSS ST
LEGAL
DESCRIPTION LOT NO ONNER /(((J
MAIL
BLOCK TRACT ADDRESS
NO OF BLDGS
SIZE OF LOT NOW ON L T CITY TEL NO
USE OF ��f/�
r DISTRICT NO GROUP MAP OCE55ED BY
BUILDINGS
BK PG
CONTRACTOR
ADDRESS IS,,,, 0a,611 CO
NNECTDATA
STATION DEPTH
CITY /" f1 TEL NO y¢,r {
,f STATE J UPPER
REGISTRATION NO �((�a�/ ❑ COUNTY MANHOLE REFERENCE {
_ ER
NO DESCRIPTION OF WORK FEE TYPE OF ION LENGTH FR ��
HOUSE SEWER CONNECTING TO Y C B P L ML TO P L }
PUBLIC SEWER @ $5 00 PC NO d
SEPTIC TANK SEEPAGE PIT OR CO IMP NO JOB NO O
PITS AND/OR DRAINFIELD @ $1000 v
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT
PRIVATE DISPOSAL SYSTEM @ $300 CC
CONNECT ADDITIONAL BLDG OR AFFIDAVIT wAlv rNT RECORD INSTR NO DATE 1O
WORK TO HOUSE SEWER a $300 r,
OVERFLOW SEEPAGE PIT DRAINFIELD LU
EXTN CESSPOOL DRYWELL MANHOLE @ SS 00 a
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING H
SEWER OR DISPOSAL SYSTEM @ $300 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT � 2 00
AUTHORIZATIONI TOTAL FEE CONNECTION CHARGE FEE
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEW APPROVALS I DATE INSPECTOR S SIGNATURE
SIGNED THIS DAY 19 n
OWNER OR NEW HOUSE SEWER (T' /
OWNERS AGENT CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS SEPTIC TANK SEEP PIT(S) <'
I HEREBY Ad6WOWLEDGE THAT 1 HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DIS POSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF AND INTEND TO DISCONNECT PLUG AND
RESIDE IN THE ASO V DESCRIBED (DENT L PROPERTY ABANDON HOUSE SEWER
SIGNATURE / ❑ I r
OF PERMITTEE BACKFILL SEPTIC TANKS
SEEP PITS) ❑ CESSPOOLS
ALIDATION ROBERT A woos
SUPERVISING MECHANICAL ENGINEER
CK M O CASH
Lriuo 6 4 7 9,. CEC 4 1 0 D 1 0 00, v