HomeMy Public PortalAbout4823 AGNES AVE_Sewer_11/15/1961_sewer connection CE808 9 e,
18A APPLICATION FOR PERMI
A64 642 D
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION FADDRESS
UILDING
JOHN A LAMBIE County Engineer
WILLIAM A JENSEN Sup t of Building OCALITY
EAREST
FOR APPLICANT TO FILL ross
LEGAL OWNER
DESCRIPTION LOT NO
BLOCK TACT BAIL
ADDRESS
NO 0 BLOSS
SIZE OF LOT NOW N LOT CITY TEL NO
USE OF DISTRICT NO GROU MAP PROCESSED BY
BUILDINGS % � �`
CONTACTOR .J
ADDRESS 7j CONNECTION DATA
CITY TEL NO STATION 7-3
DEPTH
REGISTRATION NO B COUNTY MANHOLE REFERENCE PPE
No I DESCRIPTION OF FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER- 0 $300 PE of CONNECTION LENGTH FROM •�
PETS AND/OR DRAENFGELDIT OR @ SS o0 CURB P L M L TOP L
OVERFLOW SEEPAGE PIT DRAINFIELD }
EXTN CESSPOOL DRYWELL S2 00 n.
PRIVATE DIISPOSAL CONNECTING
TO @ $1 00 Co IMP NO � JOB NO OU
CONNECT H ADDITIONALUSE BLDG OR SI 00 TRUNK PERMIT NO ROAD PERMIT NO / ~� O
SEWER REPAIR
EDI IRO R A ABANDON HOUSE @ $1 00 STATE ENCROACHMENT (—
PERMIT No U
LU
INDUSTRIAL a
WASTE APPROVAL Z
CHARGES /t
OWNER S PERM B 2 00 CONNECTION CHARGE FEE �L ���(y( Alf,
AUTHORIZATION I TOTAL FEE REIMBURSEMENT FEEIHAVE AT THIS DATE A CONTRACT WITH THE HEREIN N
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTINGAMED DWELLING, APPROVALS DATE/ INSPECTO S Sl NATURE
TO THE PUBLIC SEWER
SIGNED THIS AY 9— NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADORES SEPTIC TANK SEEP PIT(S)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I. HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL 13
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWER OR
PLUMBING AN SE SEWAGE DISPOSAL SYSTEM
1HEREBY IFY THAT 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED GU ED BY LOS ANGELES COUNTY A STHTATE OF ABANDON HOUSE SEWER
CALIFORNI R AT I AM THE LEGAL WNER 0 E ABOVE BACKFILL SEPTIC TANKS 13DESCRIB ESI TIAL PROPERTY SEEP PITS C3CESSPOOLS
SIGNAT E
OF PE
VAUDATIO3,--1 ROBERT A WOOD
CK a o (Z—HI) SUPERVISING MECHANICAL ENGINEER
t
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