HomeMy Public PortalAbout6017 AGNES AVE_Sewer_8/16/1960_ / i m P/- C'�'T
c BOB 0 8 BeAPPLICATION FOR PERMIT
E08
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL,
DEPARTMENT OF COUNTY ENGINEER
xl�oz7 ,Y
BUILDING AND SAFETY DIVISION BUILDING
JOHN A LAIE County Fmgmeer ADDRESS
MBf
CASSAT! D GRIFFIN Sup t of Buildmg LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST
LEGAL
DESCRIPTION LOT NO O OWNER,
BLOCK TRACT MAIL
ADDRESS
NOTOF BLDGS r
SIZE OF LOT NOW ON LOT CITY TEL!NOq
USE OF
BUILDINGS DISTRICT NO GROUP MAP P OCESSED BY
BK P6
CONTRACTOR 0 p�
ADDRESS O CONNE ON DATA
CITY TEL NO STATION DEPTH
TATE MANHOLE REFERENCE UPPER
REGISTRATION NO COUNTY
NO DESCRIPTION OF WOR FEE LOWER
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $y 00SEP1 TYPE OF CONNECTION LENGTH FROM
PITS IAND/OR DIC TANK RAT FIIELPAGE D T OR @ $S 00 Y CURB P L / M LL TO P L
OVEREIELD
XTNFLOW CESSPOOLADRYWELLRMANHOLE @ $2 00 `7�`V f/ -rU
HOUSE SEWER CONNECTING TO P C NO
PRIVATE DISPOSAL SYSTEM @ $1 00 CO 1 P NO JOB NO
CONNECT ADDITIONAL BLDG OR TRUNK PERMIT NO ROAD PERMIT NO
WORK TO HOUSE SEWER @ $1 00
ALTER REPAIR OR ABANDON HOUSESTATE ENCROACHMENT
@ $1 00
SEWER OR DISPOSAL SYSTEM PERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS p PERM 3 2 00 CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON APPROVALS DATE INSPECTOR S SIGNATURE
TRACTOR TO CONNECT ABOVE DES RI D EXISTING DWELLING
TO THE PUBLIC
SIGNED THIS O I NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK I
SEPTIC TANK SEEP PIT($)
ADDRESS AND/OR DRAINFIELD
1 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
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT 1 AM THF, LEGAL OWNER OF THE BOVE
DESCRIBREESID TI P TY 1 SEEPFPIT S P❑C ANKS CESSPOOLS ❑
SIGNATURE° 'i ,�
OF PERMITTE
®F VALIDATION} ROBERT A WOOD
CK m 0 1/ CASH ''/ SUPERVISING MECHANICAL ENGINEER