HomeMy Public PortalAbout5009AGNES AVE_Sewer (3) 76AG42D
S&E 8831155 APPLICATION FOR PERMIT
DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL
Deportment of County Engineer
q
County Of LOS Angeles BUILDING
JOHN A LAMBIE COUNTY ENGINEER
® CASSATT D GRIFFIN SUP T OF BUILDING LOCALITY
11,RIM
FOR APPLICANT TO FILL IN CROSS ST
LEGAL ' OWNER He'
DESCRIPTION LOT NO
/a?�� MAIL
BLOCK TRACT I ADDRESS
CITY T
NO OF BLDGS 0
SIZE LOT D 8 NOW ON LOT 62
®' EL NO
USE OFF
BUILDINGS DISTRICT NO GROUP MAP
CONTRACTOR r
-_7GG
ADDRESS CONNECTION DATA
11 �
STATION ' S T DEPTH
CITY TEL NO
MANHOLE REFERENCE 61 UPPER
7 / ATE
REGISTRATION NO / COUNTY
NO DESCRIPTI N OF WORK FEE
HOUSE SEWER CONNECTING TO TYPE OF CTION LENGTH FROM
PUBLIC SEWER @ $3 50 Y C UR2j P L M L TO P L
SEPTIC TANK SEEPAGE PIT OR
PITS AND/OR DRAINFIELD Q $3 00
OVERFLOW SEEPAGE PIT DRAINFIELD CO IMP NO A O JOB NO
EXTN CESSPOOL DRYWELL MANHOLE Q $2 00 0,
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM Q $1 00 TRUNK PERMIT NO ROAD PERMIT NO¢
CONNECT ADDITIONAL BLDG OR STATE ENCROACHMENT
WORK TO HOUSE SEWER Q $100 PERMIT NO
ALTER REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM Q $1 00 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNER S PERMIT a 1 00
AUTHORIZATION TOTAL FEE
�0 REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON APPROVALS DATE INS CTOR 5SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING ^o
TO THE PUBLIC SEWER �+ NEW HOUSE SEWER G t
SIGNED THIS /!f DAY OF 19?� CONNECT ADDITIONAL
OWNER OR a BUILDING OR WORK
OWNERS AGENT SEPTICTANK SEEP PIT(S)
ADDRESS 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 REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM THE LEGAL WNER OF THE ABOVE
DESCRIBED RESIDENTIA PERTY �'/ BACKFILL SEPTIC TANKS I-]SIGNATURE %YyiJ' SEEP PIT(S) ❑ CESSPOOLS 0�
OF PERMITTEE a
JOHN A LAMBIE COUNTYK NGINEER VALIDATIA WOOD CHIEF PLBG INSPECTOR
CK M 0 6 In
ZROBERT
LAc,0 FEB 2 4 4 550