HomeMy Public PortalAbout4932AGNES AVE_Sewer (2) r
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76A642D APPLICATION FOR PERMIT
6A64 +
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A LAMBIE County Engineer ADDRESS
WILLIAM A JENSEN Sup t of Building
LOCAL TV �G
NEAREST
FOR PPL CLAN IN CROSS ST 4oweoC GCS
4A 0
EsDESLCGAL RIPTION LOT NO OWNER
MAILBLOCK TRACT ADDRESS
NO OF BLD GS
SIZE OF LOT NOW ON LOT CITY TEL NO
USE OF DISTRICT NO GROUP MAP PROCESSED BY
BUILDINGS `^x^ BK PG
•J
CONTRACTOR U /J
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ADDRESS A COLNNECTION DATA
CITY TEL NO STATION DEPTH
STATE MANHOLE REFER E UPPER
REGISTRATION NO COUNTY IF LOWER
NO DESCRIPTION OF WORK FEE TYPE OF CONNECTIO LENGTH FROM
HOUSE SEWER CONNECTING TO Y CURB P L M L TO P L
PUBLIC SEWER @ $5 001.•1 NO
SEPTIC TANK SEEPAGE PIT OR CO IMP NO JOB O
PITS AND/OR DRAINFIELD @ S1000 V
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO
PRIVATE DISPOSAL SYSTEM @ 53 00 0
'CONNECT ADDITIONAL BLDG OR AFFIDAVIT WAIV 1411MINT RECORD INSTR NO DATE
WORK TO HOUSE SEWER @ $300 ��' {V•
OVERFLOW SEEPAGE PIT DRAINFIELD W
EXTN CESSPOOL DRYWELL MANHOLE @ $500 Lo
ALTER REPAIR OR ABANDON HOUSE H O T I E I Z
SEWER OR DISPOSAL SYSTEM @ $300 1
STATE ENCROACHMENT I
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT s z 00 CHARGES
CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE A
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSE T 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 -rl! v
BUILDING OR WORK �((� I
4ci
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION SEPTIC TANK SEEP PIT(S)
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
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 THE ABOVE DES IBED RESIDENTIAL PROPERTY ABANDON HOUSE SEWER
SIGNATURE 20# BACKFILL SEPTIC TANKS ❑
OF PERMITTEE f�MO� SEEP PITIS) ❑ CESSPOOLS ❑
ROBERT A WOOD
V ATI N� SUPERVISING MECHANICAL ENGINEER
CK M O CASH
1L'LO ' 1 C 9'." AUG 7 Q 1 0 D 5 u 0- 4
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