HomeMy Public PortalAbout6003 AGNES AVE_Sewer_3/28/1956_ D
Sa E-669 11.59
APPLICATION FOR PERMIT 1
S&E-8
DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Deportment of County Engineer
County of Los Angeles BUILDING
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JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS
@ CASSATT D. GRIFFIN, SUPT OF BUILDING y;. LOCALITY
FOR APPLICANT 7O,FILL IN C'RONS sT. ALEGAL
DESCRIPTION LOT N0. Q 43 0 OWNERMAIL
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BLOCK TRACTADDRESS
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SIZE OF LOT / s NOWOON LOTS CITY N0.
USE OF
BUILDINGS DISTRICT NO. GROUP MAP
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' CONTRACTOR S
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ADDRESS l CONNECTION DATA f
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.� �� V � STATION � r DEPTH
CITY G `�EL. NO. JJXX
M L. O. MANHOLE REFERS PER
V' C4L- +, A--� ❑ STATE � 40 LOWER
REGISTRATION N0. 8 ❑ COUNTY
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO TYPE OFTIONLENL.GTH FROM
PUBLIC SEWER @ $3.50 j. Y. URB�' P.L. M. TO P.L.
SEPTIC TANK,SEEPAGE PIT OR -
PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT, DRAINFIELD P. C. N0.
EXTN.,CESSPOOL,DRYWELL,MAN HOLE @ $2.00 CO. IMP, NO. JOB NO.
HOUSE SEWER CONNECTING TO _ r�
PRIVATE DISPOSAL SYSTEM @ $1.00 �t TRUNK PERMIT NO. ROAD PERMIT NO.
CONNECT ADDITIONAL BLDG.OR STATE ENCROACHMENT
WORK TO HOUSE SEWER @ $1.00 ` PERMIT NO.
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM @ $1.00 INDUSTRIAL
APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNERS PERMIT $ 1 00
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
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1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NA ED CON-
APPROVALS DATE INSPECTOR'S SIGNATURE
. TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING �t
TO THE PUBLIC SEWER. NEW HOUSE SEWER
SIGNED THIS DAY OF 19 CONNECT ADDITIONAL (((
OWNER OR BUILDING OR WORK
OWNERS AGENT - SEPTIC TANK,SEEP,PIT(S)
ADDRESS AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION m CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING pLTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY 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 T ABOVE _
DESCRIBED RESID L PROPERT Y. tt {/9� 1 3' BACKFILL SEPTIC TANKS❑ ` r
SIGNATURE /, �A SEEP.PIT(S) ❑ CESSPOOLS
OF PERMITTEE �/q �I
IOHN A. LAMBIE, COUNTY ENGINEER VALIDATION ROBERT A. WOOD, CHIEF PLBG. INSPECTOR
CK. � M.0. CASH
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