HomeMy Public PortalAbout5006AGNES AVE_Sewer 62
76AG42D APPLICATION FOR PERMIT
6A642
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING O
JOHN A LAMBIE County Engga100E ADDRESS /r/_ C/T_,AI/c✓\
WILLIAM A JENSEN Sup t of Building T—
LOCALITY
NEAREST
FOR APPLIC TO 'UL IN CRDSS ST
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DESCRIPTION LOT NO OWNER
MAIL ,.!
BLOCK TRACT ADDRESS
NO OF BLDG5 /'
SIZE OF LOT NOW ON LOT CITY (� TEL NO T
USE OF
BUILDINGS DISTRICT NO GROUP MAP PROCESSED BY
BK PG/
CONTRACTOR J`
ADDRES s s _ CONNECTION DATA
CITY '^� O ATION DEPTH
f TEL NO
REGISTRATION NO p� Ly5 ATE MANHOLE REFERENCE UPPER
(iV El Ly
NO DESCRIPTION OF WORK FEE TYPE FCON EC LENGTH FROM
SE SEWER CONNECTING TO Y L P L ML TO P L
ELIC SEWER @ $5 00 PC NO
SEPTIC TANK SEEPAGE PIT OR CO IMP NO .108 NO U
PITS AND/OR DRAINFIELD @ $1000
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO G
PRIVATE DISPOSAL SYSTEM @ S3 00 0
CONNECT ADDITIONAL BLDG OR AFFIDAVIT I WAIVER EASEMERT RECORD INSTR NO DATE
WORK TO HOUSE SEWER @ $300
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL MANHOLE @ $5 00
ALTER REPAIR R A BANDON_.,4i OUSE HWY OR ST WIDENING
SEWER OR D OSAL SY @ 3300 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
OWNER S PERMIT CHARGES
AUTHORIZATION I TOTAL FEE O CONNECTION CHARGE FEE
1 HAVE 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 SIGNATURE
SIGNED THIS DAY I z tg_
OWNER OR �✓/ NEW HOUSE SEWER
OWNERS AGENT_
CONNECT ADDITIONAL
ADDRESS
BUILDING OR WORK
SEPTIC TANK SEEP PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE 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 ❑ DRYWELL
1 HEREBY CERTIFY TH M PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
LICENSED AS REQUIRE B OS ANGLES COUNTY AN , TATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT A T E LEGAL OWN F AN NTE NO TO DISCONNECT PLUG AND
RESIDE IN THE ABO E D SCRIBED RESIDE PR TY ABANDON SESEW WE.
SIGNATURE BACKFILL SEPTIC TANKS
OF PERMITTEE ` SEEP PITS) ❑ CESSPOOLS ❑
ALIDATIOPP--) ROBERT A WOOD
CK SUPERVISING MECHANICAL ENGINEER
M O CAS
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