HomeMy Public PortalAbout6032 AGNES AVE_Sewer_2/10/1956_ o
S&E68It 55
APPLICATION FOR PERMIT 1
S E DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL
Deportment of County Engineer
County Of Los Angeles FADDRESS
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JOHN A LAMBIE COUNTY ENGINEER lO +� LT! 1G �7
® CASSATT D GRIFFIN SUP T OF BUILDING TY �F�:�,.--GC C,, T
FOR APPLICANT TO FILL IN CROSS ST
I
LEGAL LOT (r-Z OWNER
DESCRIPTION LOT NO / MAIL //``��
BLOCK TRACT Q� / ADDRESS aO (3 6F
/WTX / / D NOW ON LOTOF DGS CITY �/t �(, y CST'TEL NO
SIZE OF LOT
BUELDINGS G-OF J, // a [?�7`�� DISTRICT 0 GROUP BK will MAP PG
CONTRACTOR IkS"'V& Gi S
/�/ /1 ( L�� CONNECTION DATA
ADDRESS (� L_V �i
CITY r�1v"-ze CST TEL NO �/ -77��a STATION 37L6-:tff'� DEPTH �Q O
MANHOLE REFERENCE /_ � q �i L� UGOW
REGISTRATION NO / O STATE (p �7 LOWER
COUNTY
NO DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO TYPE OF CO CTION LENGTH FROM d
PUBLIC SEWER @ $3 SO �Q Y P L M L TO P L
SEPTIC TANK SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ $3 00
OVERFLOW SEEPAGE PIT DRAINFIELD P C NO
EXTN CESSPOOL DRYWELL MANHOLE @ $2 00 ro IMP NO JOB NO
HOUSE SEWER CONNECTING TO �+ ��y
PRIVATE DISPOSAL SYSTEM @ $1 00 TRUNK PERMIT NO ROAD PERMIT NO VV 879
CONNECT ADDITIONAL BLDG OR STATE ENCROACHMENT f
WORK TO HOUSE SEWER @ $1 00 O PERMIT NO
ALTER REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM @ $1 00 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE r
OWNER S PERMIT $ 1 00
AUTHORIZATION TOTAL FEE 6-13—'a
REIMBURSEMENT FEE 7
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON APPROVALS DATE INSPECTOR SSIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING /`
TO THE PUBLIC SEW R ,�j L NEW HOUSE SEWER �-Lf hmeA
SIGNED THIS AY OF �e'V 1y�c CONNECT ADDITIONAL
OWNER OR1 '>77 BUILDING OR WORK
OWNERS AGENF',/�J ,f T �'-�
ADDRESS
60V7evV �� / F��j �iT AND/SEPTOR TDRAINFIELD
ANK SEEP PIT(S)
DI HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
ANSTATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWER OR
PLUMBING AND SEWERS _SEWAGE DISPOSAL SYSTEM
1ICHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LENSED AS REQUIRED LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR TH A
I M THE L GAL OWNER OF'THE ABOVE
DESCRIBED RESIDENTIA PROPERTY IBACKFILL SEPTIC TANKS 0_1k ,-�
SIGNATURE / SEEP PIT(S) ❑ CESSPOOLS Z
OF PERMITTEE(-
JOHN
ERMITTEE JOHN A LA IE CCKINTY ENGINEER VALIDATION ROBERT A WOOD CHIEF PLBG INSPECTOR
CK N 0CAS
i CO2 7 2 N FEB 10 4 550