HomeMy Public PortalAbout6053 AGNES AVE_Sewer_10/11/1972_ 76A 642D -CE808-10 71 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN
L CR.ss STiL.1,004?d?vr-�5
/
DESCRIPTION LOT NOLEAL ✓ S OWNER f'/ �0✓y
MAIL
BLOCK TRACT Y.J 7 /
ADDRESS
SIZE OF LOT NOWOON LOTBLDGS CITY TEL NO
USE OF
BUILDINGS /y .e DISTRICT NO GROUP BX MAP P//_ /PR OC ESESJS Ep BY
CONTRACTOR;��L�� / �L�,/��tr 1A �� !/ 1-3" +✓�'_`/�/�'��
ADDRESS//TT;� /O'vr 1eey CONNECTION DATA
CITY
�L7,40,i 'g- TEL NO 7� D'J-.6' STATION �S/r DEPTH
+�yy rLIC d� UPPER
LICENSE NO rj"4�/ a a� CLASS MANHOLE REFERENCE f'/ / /Y� LOWER
NO DESCRIPTION OF WORK FEE TYPE OFC TION v LENGTH FROM y �`-
HOUSE SEWER CONNECTING TO rY iCUR P L M L TO P L
PUBLIC SEWER @ $7 00 / 04� PC NO
SEPTIC TANK SEEPAGE PIT OR 6 JOB NO
PITS AND/OR DRAINFIELD @ 51000 CO IMP NO
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO d
PRIVATE DISPOSAL SYSTEM @ $300 O
CONNECT ADDITIONAL BLDG OR AFFIDAVIT I WAIVES I EASEMENT RECORD INSTR NO DATE V
WORK TO HOUSE SEWER @ $300
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL @ $5 00 O
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING F-
S EWER
-SEWER OR DISPOSAL SYSTEM @ S300 STATE ENCROACHMENT W
MANHOLE $7 00 PERMIT NO h
INDUSTRIAL
����+ WASTE APPROVAL
O•VMR S PERMIT S 3 00 CHARGES
AUTHORIZATION TOTAL FEE �O �Q CONNECTION CHARGE FEE
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER APPROVALS DATE INS CTOR IGNATURE
SIGNED THIS PAY O�F/� 19_
OWNER A F\'k J_ryp� _" _ NEW HOUSE SEWER
OWNERS AGEN �..�/�
—� CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
SEPTIC TANK SEEP PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
LICENSEDAS REQUIRED S ANG ES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR TH,/yl AM THOWNER OF AND INTEND TO DISCONNECT PLUG AND
RESIDE IN THE BO ES ESID IAL PROPERTY ABANDON HOUSE SEWER
SIGNATU I ❑
1"fT BACKFILL SEPTIC T KS
SEEP PIT IS) [ ESSPOOLS ❑ v
VALIDATION CK M 0 CASH
� O01 77N OCT 11 1 0 o 1000-
Q