HomeMy Public PortalAbout4839AGNES AVE_Sewer C E 849 12 Be
7eA 642D APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING /e
JOHN A LAMBIE COUNTY ENGINEER ADDRESS /"
COLEMAN W JENKINS SUPT OF BUILDING (�
LOCALITY
NEAREST fi 7.11
FOR APPLICANT TO FILL Di CROSS ST
L GAL
DESCRIPTION LOT NO � OWNER (� p
— [] MAIL
CR
BLOCK TRACT * i / ADDRESS
NO OF SIZE OF LOT NOW ON LOT 6 CITY p W�� r� -EL NO /
USE OF �y DISTRICT N�R�j MAP PROCESSED BY
BUILDINGS
BK PG
CONTRACTOR U A v /I a�`(�j7 <Q kw.- �O � I' C�
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ADDRESS C .z (P4It-j CON=C ON DATA
CITY TEL NO C-/ ION417t 3e DEPTH
STATE 7 ! LIC MANHOLE REFERENCE
LICENSE NO ! Q y LIC ��( L OWER
NO DESCRIPTION OF WORK FEE TYPE OF CO EC O LENGTH FROM
HOUSE SEWER CONNECTING TO Y M L TOP L
PUBLIC SEWER $500
SEPTIC TANK SEEPAGE PIT OR r� P C NO
PITS AND/OR DRAINFIELD $1000 CO IMP NO C� JOB NO
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO
PRIVATE DISPOSAL SYSTEM $300 0
CONNECT ADDITIONAL BLDG OR AFFIDAVIT WAIVER E1IEEMENT RECORD INSTR NO DATE U
WORK TO HOUSE SEWER $300
OVERFLOW SEEPAGE PIT DRAINFIELD
EXT N CESSPOOL DRYWELL MANHOLE $S 00 O
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING U
SEWER OR DISPOSAL SYSTEM $300 W
STATE ENCROACHMENT CL
.4�+7 PERMIT NO N
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNER S PERMIT s
AUTHORIZATION TOTAL FEE CrD 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 APPROVALS
TO THE PUBLIC SEWER 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 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
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 ABOVE DESCRIBED RESIDENTIAL PROPERTY ABANDON HOUSE SEWER
SIGNATURE u,,,�Dom^ ��` BACKFILL SEPTIC TANKS 11OF PERMITTEE SEEP PIT(S) ❑ CESSPOO It. ❑
VALIDATION JACK R ALLEN
CK M O CASH SUPERVISING MECHANICAL ENGINEER
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