HomeMy Public PortalAbout4835AGNES AVE_Sewer (4) i
;6A OdD ° APPLICATION FOR PERMIT
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COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING At ie
JOHN A LAMBIE COUNTY ENGINEER ADDR SSf
COLEMAN W JENKINS SUPT OF BUILDING LOC
NEAREST
FOR APPLICANT TO FML IN CROSS ST ,-LEAL
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DESCRIPTION LOT NO OWNER `IV IPAI-f
MAIL
BLOCK TRACT ♦ A — g,3, JJ ADDRESS LZ LO rc l'.Nell
NO OF BLOCS
SIZE OF LOT NOW ON LOT j CITY A lifiviN _EL NO
USE OF
BUILDINGS DISTRICT NO GROyp MAP PROCESSED BY
BK PC
CONTRACTOR , D N r qM ,f Wer CO• ,6.ul!p 1i 5- �.5-
G1(.,
ADDRESS 6 t N�/'dt / ! CONNECTION DATA
CITY G�f� TEL NO K�F/__0 /Z ION EPTH
STATE LIr
LICENSE NO CLASS L MANHOLE REFERENCE O0O
o e LOWER
NO DESCRTPTION-OF WORK FEE TYPE OF C NE I LENGTH FROM
HOUSE SEWER CONNECTING TOY ML TO P L
PUBLIC SEWER ! $500
SEPTIC TANK SEEPAGE PIT OR ! PC NO
PITS AND/OR DRAINFIELD G $1000 CO IMP NO dJ JOB NO
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO CL
PRIVATE DISPOSAL SYSTEM G 5300 C)
CONNECT ADDITIONAL BLDG OR AFFIDAVIT I WlIVEE I EASEMENT RECORD INSTR NO DATE U
WORK TO HOUSE SEWER G S300
OVERFLOW SEEPAGE PIT DRAINFIELD
EXT N CESSPOOL DRYWELL MANHOLE G $9 00 O
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING U
SEWER OR DISPOSAL SYSTEM G $300 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT s z o0 CHARGES
AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN N MED CON REIMBURSEMENT FEE
TRACTOR TO-CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER APPROVALS 7AT� INSPECTOR S SIGNAURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT_ CONNECT ADDITIONAL J
ADDRESS BUILDING OR WORK
SEPTIC TANK SEEP PIT(S)
1 HEREBY ACKNOWLEDGE THAT I 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 ❑
1 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
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF AND INTEND TO DISCONNECT PLUG AND
RESIDE IN THE A VE-DESCRIBED RESIDENTIAL PROPERTY ABANDON HOUSE SEWER
SIGNATURE Si- �,w �. BACKFILL SEPTIC TANKS ❑
OF PERMITTEE ll�������""'^"""""""��� SEEP PIT(5) ❑ CESSPOOLS
VALIDATION JACK R ALLEN
CK M G CASH SUPERVISING MECHANICAL ENGINEER
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