HomeMy Public PortalAbout4958AGNES AVE_Sewer (6) 76A6420 3 64 APPLICATION FOR PERMIT
i6A64
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A LAMBIE County Engineer ADDRESS (� S
WILLIAM A JENSEN Sup t of Building
LOCALITY
NEAREST Q
FOR APPLICANT TO FILL IN CROSS 5T
LEGAL /O `
DESCRIPTION LOT NO L OWNER C
MAIL
BLOCK TRACT ADDRESS
OSLOGS
SIZE OF LOT
{D/, / NOW ON LOTCITY TEL NO --���j
USE OF /
BUILDINGS f DISTRICT�NO GROUP MAP PROCESSED BY
BK PG
CONTRACTOR J � ✓ ��
ADDRESS �y �/ C CONNECTION DATA
CITY G !/ TEL NO STATION �Q /� DEPTH
STATE MANHOLE REFS ENCS V
REGISTRATION NO COUNTY , 3 LOWE
NO DESCRIPTION OF WORK FEE TYPE O CONNECTI LENGTH FROM
HOUSE SEWER CONNECTING TO Y CURB P L ML TOP L
PUBLIC SEWER @ $5 00
SEPTIC TANK SEEPAGE PIT OR J C NO
PITS AND/OR DRAINFIELD 510 00 CO IMP NO JOB NO d
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO 0
PRIVATE DISPOSAL SYSTEM @ S300
CONNECT ADDITIONAL BLDG OR AFFIDAVIT wAIV[R I [A[[M[NT RECORD INSTR NO DATE
WORK TO HOUSE SEWER @ 33 00 O
OVERFLOW SEEPAGE PIT DRAINFIELD t-
EXTN CESSPOOL DRYWELL MANHOLE @ $500 U
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING d
SEWER OR DISPOSAL SYSTEM @ $300 STATE ENCROACHMENT N
PERMIT NO Z
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT $ 2 Oo CHARGES
AUTHORIZATION TOTAL FEE O O CONNECTION CHARGE FEE
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEVVq /� APPROVALS DATE INSPECTOR 5 SIGNATURE
SIGNED THIS D*.y 3%'
OWNER OR NEW HOUSE SEWER
OWNERS AGENT
� CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
SEPTIC TANK SEEP PITS)
I HEREBY ACKNOWLEDGE THAT 1 VE 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 [IDRYWELL ❑
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THA I AM THE LEGAL OWNER OF AND INTEND TO DISCONNECT PLUG AND
RESIDE IN THE A DESC RESI�IAL P ERTY ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMITTE ❑
SEEP PIT(5) ❑ CESSPOOLS
C,�,ALIDATION ROBERT A WOOD
SUPERVISING MECHANICAL ENGINEER
GK M O CASH
jAr,c3296'l-_;l FEB 6 1 0 Q 500