HomeMy Public PortalAbout6059 AGNES AVE_Sewer_5/31/1976_ dze_�_L. a-17-
76A 6420 -CE808-10 71 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER / /��± '
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS V6V �V�s /'/0 p/y,S v---
/
LOCALITY n"*tc
NEAREST
FOR APPLICANT TO FILL IN CROSS ST A
LEGAL /w'
DESCRIPTION pp LOT NO �� OWNER J/�/(�fJ/� �J ��Ll
MAIL
BLOCK TRACT �jj / ADDRESS Q ^ ` 011,124
NO by
SIZE OF LOT NOW
OON LOTS CITY �.0/!Y` ��( C/?� TEL NO S: 4
USE OF
BUILDINGS �SCA�C� rJSC X31257 DISTRICT NO GROUP BK MAP PSSED B/i ,)Y
CONTRACTOR O(/ 7- v
ADDRESS CONNECTION D
CITY TEL NO STATION/0/.// DEPTH
STATE LIC M OLE REFE RENC
LICENSE NO CLASS a � l LOWER
NO DESCRIPTION OF WORK FEE TYPE OFNN ION LENGTH FROM /
HOUSE SEWER CONNECTING TO �v Y CURB P L M L TO
PUBLIC SEWER @ $7 00
SEPTIC SANK SEEPAGE PIT OR `� � P C NO
PITS AND/OR DRAINFIELD @ E10 00 CO IMP NO JOB NO
}
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO d
PRIVATE DISPOSAL SYSTEM @ S300 O
CONNECT ADDITIONAL BLDG OR AFFIDAVIT I WAIVC4 I 115[M[NT RECORD INSTR NO DATE u
WORK TO HOUSE SEWER @ $300
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL 0 $500 O
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING
SEWER OR DISPOSAL SYSTEM @ $3 00 STATE ENCROACHMENT W
PERMIT NO d
MANHOLE $7 00
INDUSTRIAL W
/ WASTE APPROVAL Z
OWNERS PERMIT $ L 5P CHARGES
AUTHORIZATION TOTAL FEE r 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 INSPECTS SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT
CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS SEPTIC TANK SEEP PIT(S)
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITHALL 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
LICENSED AS REQUIRED BY LOS ANGLES COUNTY ANDSTATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT AM THE LEGAL OWNER OF AND INTEND TO DISCONNECT PLUG AND
RESIDE IN THE ABO E DESCRIBED RESIDE ROPERTY ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERM"TEE
SEEP PIT(S) ❑ CE SSPOOLSI®
VALIDATION M O CASH
66 -)-,°MAY 316 D 1 500A�d
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