HomeMy Public PortalAbout4949AGNES AVE_Sewer (2) D
S&E 6e
APPLICATION FOR PERMIT 1
s g E DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Department of County Engineer
County of Los Angeles AUILD'DRSG
JOHN A LAMBIE COUNTY ENGINEER
® CASSATT D GRIFFIN SUP T OF BUILDING LOCALITY
FOR APPLICANT TO FILL IN -Ross ST
LEGAL
DESCRIPTION LOT NO OWNER
MAIL
BLOCK TRAC ADDRESS S
SIZE OF LOT NOW ON LOT CITY ,� TEL NO /
USE OF
BUILDINGS G DISTRICT NO GROUP MAP
B& PG
CONTRACTOR �,3 ;
CF�l
ADDRESS
ONNECTION DATA L.
TEL NO STATION DEPTH
CITY
MANHOLE REFERENCE UPPER
JM STATE a ' LOWER
REGISTRATION NO ❑ COUNTY
NO DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO TYPE OF CONNECTION LENGTH FROM
PUBLIC SEWER @ $3 50 Y CURB P L M L TOP L
SEPTIC TANK SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ $3 00
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL MANHOLE @ $Z CO IMP NO 00 f D JOB NO
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM @ $1 00 TRUNK PERMIT NO ROAD PERMIT NO
CONNECT ADDITIONAL BLDG OR STATE ENCROACHMENT
WORK TO HQ.USE SEWER @ $1 00 PERMIT NO
ALTER REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM @ $1 00 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNER S PERMIT $ 1 00
REIMBURSEMENT FEE
AUTHORIZATION TOTAL FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON APPROVALS DATE INSPECTOR SSIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWE s / NEW HOUSE SEWER
SIGNED THIS AY OF 19 r` CONNECT ADDITIONAL
OWNER OR BUI ING OR WORK
OWNERS AGENT SEPTICTANK SEEP PIT(S) vv
ADDRESS.-
DDRESS AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWER OR '
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGIS ED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUN AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM THE LE 0 OF THE ABOVE
DESCRIBED RESIDENTIAL OPERTY BACKFILL SEPTIC TANKS❑
SIGNATURE SEEP PITS) ❑ CESSPOOLS[:)
OF PERMITTEE
JOHN A LAMBIE CO TY ENGINEER ALIDATION ROBERT A WOOD CHIEF PLBG INSPECTOR
CK EI 0 CASH
'6883- APR 5 4 200