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HomeMy Public PortalAbout4835AGNES AVE_Sewer (3) �Qe 76A v..E21) ` APPLICATION FOR PERMI COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION BUILDING JOHN A. LAMBIE. COUNTY ENGINEER ADDRESS Yf^ /✓�� COLEMAN W. JENKINS, SUPT. OF BUILDING LOCALITY CROSSSST. LD Wef /T V FOR APPLICANT TO FILL IN r LEGAL DESCRIPTION LOT NO. OWNER L e -io If MAIL BLOCK TRACT ADDRESS SIZE OF LOT NOWOON LOTS CITY If,I6(N 1P' '1 TEL. NO. 3 - 97,7)/ USE OF BUILDINGS DISTRICT NO. GROUP MAP PROCESSED BY /`'[e/{ /� /' i_ 7 BOK PG /- /7 CONTRACTOR (�! M"1 , 1 e'fl/+PI (a•+• `/ r© C/" ADDRESS /�/� 6 ��.✓fry. / CONNECTION DATA CITY /d f✓/74�'/�TEL. NO. (f 17/ Z ION e DEPTH STATE I �1 3 /_ / CLASS /ems MANHOLE REFERENCE�� LOWER LICfiNSE NO. ( aVV V NO. 1 DESCRIPTION OF WORK FEE TYPE OF NN T LENGTH ROM HOUSE SEWER CONNECTING TO Y. P. M.L.TO P.L. PUBLIC SEWER @ $5.00 SEPTIC TANK.SEEPAGE PIT OR 7 i'�r P.C.NO. CO.IMP. NO. J (�j' JOB NO. PITS AND/OR DRAINFIELD @ $10.00 HOUSE SEWER CONNECTING TO PRIVATE DISPOSAL SYSTEM @ $3.00 TRUNK PERMIT NO. ROAD PERMIT NO. �{ 0�.. V CONNECT ADDITIONAL BLDG.OR AFFIDAVIT I WAIVER I EASEMENT RECORD.INSTR,NO. DATE V WORK TO HOUSE SEWER @ S3.00 OVERFLOW SEEPAGE PIT,DRAINFIELD EXTN..CESSPOOL.DRYWELL.MANHOLE @ $5.00 ALTER,REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING C-) W SEWER OR DISPOS L Y TEM @ $3.00 STATE ENCROACHMENT C" PERMIT NO. f/)� INDUSTRIAL WASTE APPROVAL OWNERS PERMIT g CHARGES AUTHORIZATION TOTAL FEE _216-00 CONNECTION CHARGE FEE I HAVE 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 INSPECTOR'S SIGNATURE SIGNED THIS DAY OF 19_ OWNER OR NEW HOUSE SEWER ? . OWNERS AGENT_ CONNECT ADDITIONAL ADDRESS BUILDING OR WORK SEPTIC TANK,SEEP,PITS) 7 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 I PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑ - J I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER.REPAIR.SEWER OR LICENSEDAS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND RESIDE IN. TH E ABO DESCRIBED RESIDENTIAL PROPERTY. ABANDON HOUSE SEWER SIGNATURE OF PERMrTTEE '`✓Lam{! BACKFILL SEPTIC TANKS ❑ Jr SEEP,PITS) ❑ CESSPOOLS VALIDA'T'ION JACK R. ALLEN SUPERVISING MECHANICAL ENGINEER CK M.O. CASH � Ar,5565c-- JUN 2611 D 25.00-