HomeMy Public PortalAbout5004AGNES AVE_Sewer CE8011 3 62
76A6420 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A LAMBIE County Engineer ADDRESS V T s
WILLIAM A JENSEN Supt of Building ,.�—
LOCALITY �
NEAREST 5f�--
FOR APPLICA T TO FILL IN CROSS 6T w �T•��� J
LEGALOf
DESCRIPTION LOT NO ♦ 6 OWNER
MAIL /
BLOCK TRACT � ADD RESSry � � •�/.11� ��-
NO OF BLDG -77
SIZE OF LOT NOW ON LOT CITY TEL NO
USE OF •� DISTRICT NO GROUP MAP PROC SSED BY
BUILDINGS
BK PG
ADDRESS — / —CONNECTION DATA
`^ ATION
CITY TEL N DEPTH
ITAT
REGISTRATION NO
COUNTY MANHOLE REFERENCE UPPER
NO DESCRIPTION OF WORK FEE TYPE OF CON CT LENGTH FROM
HOUSE SEWER CONNECTING TO Y C ly M L TO P L
PUBLIC SEWER $5 00 PC
NO
SEPTIC TANK SEEPAGE PIT OR CO IMP NOJOB NO V
PITS AND/OR DRA(NFIELD @ $1000
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO 7
PRIVATE DISPOSAL SYSTEM @ $300
�J
CONNECT ADDITIONAL BLDG OR AFFIDAVIT WAIVER BASEMENT RECORD INSTR NO DATE
WORK TO HOUSE SEWER @ $300
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL MANHOLE @ $500 y
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING
SEWER OR DISPOSAL SYSTEM @ $3 00 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
OWNER$ PERMIT $ i CHARGES o0
AUTHORIZATION TOTAL FEE 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 SEWER APPROVALS DATE INSPECTOR S SIGN TURE
SIGNED THIS DAY OF 19_ f
OWNER OR NEW HOUSE SEWER
OWNERS AGENT_
CONNECT ADDITIONAL 0 r
ADDRESS BUILDING OR WORK
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION SEPTIC TANK SEEP PIT(S)
AND/OR DRAINFIELD
AND STATE THAT THE ASOVE 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
LICENSED AS REQUIRE Y LOS ANGLES COU AND ST E OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THA1,111 AM HE LEGAL OWN AND IN NO TO DISCONNECT PLUG AND
RESIDE IN THE A VE SCRIBED RESIDE PRO RT ABANDON HOUSE SEWER I�� ��✓/�(/�jLj/,A'/
SIGNATURE CK FILLSEPTICTANKS ❑per hh ) �g#��y�7/•
OF PER MTTTE /
SEEP PIT(S) ❑ CESSPOOLS
ALIDATIONN ROBERT A WOOD
CK M O CASH
SUPERVISING MECHANICAL ENGINEER
L1 � � � 1261.0 Mry 21GG 700 `�