HomeMy Public PortalAbout4908AGNES AVE_Sewer (2) 6A64 ,51
7APPLICATION FOR PERMIT
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COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING"/,p
JOHN A LAMBIE County Enggtnnee: ADDRESS
WILLIAM A JENSEN Sup i of Buildwg_ LOCALITY
NEAREST
FOR APP MIN CROSS ST
LEGAL OWNER
DESCRIPTION LOT NO
BLOCK TRACT MAIL-14
ADDRESS
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NO OF BLDGS
E
S12OF LOT 10 � NOW ON LOT CITY' TEL NO
USE OF
BUILDINGS K PGA DISTRICT GROUP MAP PROCESS BY
f
CONTRACTOR O NO
ADDRESS CONNECTION DATA
CITY TEL NO/ 0 DEPTHSTATE
! i
REGISTRATION NO B COUNTY MANHOLE REFERENCE , LOWE
WS
No I DESCRIPTION OF WORK FEEI
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $300 TYPE OF CONNECTION LENGTH FROM
SEPTIC TgNK SEEPAGE PIT OR Y CURB P L N L TO P L
PITS AND/OR DRAINFIELD 0 $300
OVERFLOW
CESSPOOL
SSPOOLGDRYWELLAINFIELD @ $2 00 CIS.
HOUSE SEWER CONNECTING TO P C N0 Q
PRIVATE DISPOSAL SYSTEM @ S1 00 CO IMP NO JOB NO
CONNECT ADDITIONAL BLDG OR TRUNK PERMIT NO ROAD PERMIT N
WORK TO HOUSE SEWER @ 3100
ALTER REPAIR OSAL SYSTEM HOUSE @ S1 00 STATE ENCROACHMENT Q
PERMIT NO (�
INDUSTRIAL YJ
WASTE APPROVAL
_ y
CHARGES Z
OWNERS PERMIT $ CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE ()'D REIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR S SIGNATURE
TO THE PUBLIC SEWER
SIGNED THI DAY OR 19 NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADDRESS— SEPTIC TANK SEEP PIT(S)
AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT t 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 AND SEWERS SEWAGE DISPOSAL SYSTEM__
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR TH T AN THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDEN IA PROPERTY BACKJILL
PITS SEPTIC TANKS
❑ C ❑
SIGNATURE
OF PERMITTE
VALIDATION ROBERT A WOOD
K Y
C0 CAstl SUPERVISING MECHANICAL ENGINEER
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