HomeMy Public PortalAbout6050 AGNES AVE_Sewer_7/7/1978_ 76A 6421D - CE808 - 9/73 APPLICATION FOR PERMIT U
COUNTY OF LOS ANGELES SEWER—SEWA DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING �5o TT Agnes V��
ADDRESS WJ 1V• GYM
LOCALITY Temple Cit
NEAREST
FOR APPLICANT TO FILL IN CROSS 6T
LEGAL 5-5/ Rosemead Construction
[DESCRIPTION LOT NO OWNER (y7 L �+
OCK TRACT �(O/ MAIL 1816 Sari Gabriel lv
�/ ADDRESS C�'%
ZE OF LOT So i[ �� NOW OON LOT" CITY San Gabriel TEL NO f 3-41110SE OFDISTRICT NO GROUP MAP ESSED BY
UILDINGS
CONTRACTOR
f-/ ,-3,(,
ADDRESS 4265 d riAve, CONNECTION DATA
El MonLie TEL NO "30078 STATION DEPTH
STATE LIC2 MANHOLE REFERENCE UPPER
LICENSE NO 231 741 CLASS C36-20 LOWER
NO I DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y CURB P L ML TOP L
PUBLIC SEWER @ $7 00
P C NO
SEPTIC TANK SEEPAGE PIT OR
PITS ANO/OR DRAINFIELD $1000 CO IMP NO JOB NO
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO
PRIVATE DISPOSAL SYSTEM $300
CONNECT ADDITIONAL BC011-OR0
AFFIDAVIT WAIVI[ [A [NT RECORD INSTR NO DATE f
WORK TO HOUSE SEWER ® 00 i d
OVERFLOW SEEPAGE PIT DRAINFIELD O
EXTN CESSPOOL DRYWELL ® $500 V
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING
SEWER OR DISPOSAL SYSTEM 5300 STATE ENCROACHMENT _ C>
MANHOLE $7 00 PERMIT NO C�
INDUSTRIAL W
D_
WASTE APPROVAL C7
Z
CHARGES
OWNER S PERMIT $
CONNECTION CHARGE FEE
AUTHORIZATION rorAL FEE
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS
TO THE PUBLIC SEWER DATE INSPECTOR S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER n
OWNERS AGENT
CONNECT ADDITIONAL 1/ q �n.JrfI AJ— Imo'
ADDRESS BUILDING OR WORK
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION SEPTIC TANK SEEP PIT(6)
AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING a
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CAL IA OR T THE LEGAL OWNER OF AND INTEND TO
RESIDE IN THE B V D 6CRI!��OPERTY DISCONNECT PLUG AND
ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PEit MITTEE SEEP PITS) ❑ CESSPOOLS
❑ t
VALIDATION <�K M 0 CASH
Ear QN-SATION - -
POLICY }EOLBER �+ 5 0 4 t`-',JUL 7 10 0 `l ��G U ®4,
POLICY NUP4BER w 0 /,s5_33 Sy
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