HomeMy Public PortalAbout6009 AGNES AVE_Sewer_6/16/1961_ D
CE808 a as APPLICATION FOR PE MIT
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COUNTY OF LOS ANGELES SEWER-SEWAGE TPOSALL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING / O�
91
JOHN A LAMBIE County Fmgmeer ADDRESS (p
CASSATi D GRIFFIN Sup t of Building LOCALITY
NEAREST
FOR APPLICANT TO FILL,IN _caoss sT
LEGAL 14 V2- /2 -0,4
7
DESCRIPTION LOT NO OWNER
MAIL
BLOCK TRACT �6 ADDRESS
NO OF BLDGS
SIZE 9 LO NOW ON LOT CITY TEL NO
USE OF
BUILDINGS / DISTRICT NO GROUP MAP PROCESSED BY
BK PG
CONTRACTOR
ADDRESS o2 G v COCNNECTION DATA
CITY TEL NO G fC3 p 7 STATION DEPTH
STATE MANHOLE REFERENCE
No DESCRIPTION O
REGISTRATION COUNTY i L WER
OF WOR FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3 00 OO
SEPTIC TANK SEEPAGE PIT OR TYPE OF NECT LENGTH FROM `7C
PITS AND/OR DRAINFIELD @ $3 00 Y CURB P L M L TO P L L}ZJ
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL MANHOLE @ $2 00
HOUSE SEWER CONNECTING TOP C NO
PRIVATE DISPOSAL SYSTEM Q $1 00 CO IMP NO 13 d 41JOB NO
CONNECT ADDITIONAL BLDG OR
WORK TO HOUSE SEWER TRUNK PERMIT NO ROAD PERMIT NO O
@ $1 00
ALTER REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
SEWER OR DISPOSAL SYSTEM @ $1 00 PERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNER S PERMIT $ 2 00 CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE 7 00 REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON APPROVALS DATE INSPECTOR S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER
SIGNED THIS DAY OF J 9_ NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADDRESS SEPTIC TANK SEEP PIT(S)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL❑ DRYWELL❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND a
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER f
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIA PROPER BACKFILL SEPTIC TANKS �}
SIGNATURE SEEP PITS) ❑ CESSPOOLS❑
OF PERMITTEE
( .,VALIDATION ROBERT A WOOD
cu✓Cu//// x p cult SUPERVISING MECHANICAL ENGINEER
6 8 7 m JuT'l 6 1 O p 500 n