HomeMy Public PortalAbout4906AGNES AVE_Sewer ` ,%642V
75,%642V APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSA
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING o
WOHN A. LAIE County Engc�maeeer ADDRESS
ILLIAM AMBJENSEN Sup t of Buildmg LOCALITY
NEAREST
FOR APPLICANT TO F714. IN CROSS Sr
LEGAL -7 OWNER
DESCRIPTION LOT NO
BLOCKTRACT MAIL
ADDRESS
SIZE OF LOT /J.1 140-OF
ON LOT
BLDGS� OCITY TEL NO
USE DISTRICT NO GROUP MAP PROCESS Y
BUILDDI NGS
,^
BE PG t
CONTRACTOR D
ADDRESS CONNECTION DATA
CITY TEL NO ION & DEPTH
STATE MANHOLE REFERENCE
REGISTRATION NO B COUNTY ER
No I DESCRIPTI OF FE
HOUSE SEWER CONNECTING TO /
PUBLIC SEWER @Abo TYPE OF CONNECTION L NGTH FROM
PITS AND/OR SEEPAGE
OR OO Y CURB P L M L TO P L
OVERFLOW SEEPAGE PIT DRAINFIELD d
EXTN CESSPOOL DRYWE L S 00
HOUSE SEWER CONNECTING TO P C NO O
PRIVATE DISPOSAL SYSTEM @ $100 CO IMP NO JOB NO V
CONNECT ADDITIONAER BLDG OR 00
WORK TO HOUSE SEWTRUNK PERMIT NO ROAD PERMIT NOT VL CL
SEWER REPAIR
R DISPOS ABANDON
NOOSE @ '00 STATE ENCROACHMENT O
PERMIT NO u
INDUSTRIAL a
WASTE APPROVAL Z
CHARGES
OWNERS PERMIT $ 2 00 CONNECTION CHARGE FEE
AUTHORIZATION 1 TOTAL FEF REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN N ED CON
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATES INSPECTQR S SIGNATURE
TO THE PUBLIC SEWER
SIGNED THIS DAY OF 19_ NEW HOUSE SEWER
OWNER OR / CONNECT ADDITIONAL
OWNERS AGENT n BUILDING OR WORK
ADDRESS SEPTIC TANK SEEP PIT(S)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT t HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL El DRYWELL rl
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTE
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESID TI PROPERTY SECKFILL PIT(S)P❑ CESSPANKS ❑LS
SIGNATURE
OF PERMITTE
VALDA � ROBERT A WOOD
et At
SUPERVISING MECHANICAL ENGINEER
�` LAr' 1 6 2 O � P R 2 4. 1 0 0 700
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