HomeMy Public PortalAbout5028AGNES AVE_Sewer M
` TEMPLE CITY
CEBf842D APPLICATION FOR PERMIT
76A2D
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A LAMBIE COUNTY ENGINEER ADDRESS5028 N. Agnes Ave.
COLEMAN W JENKINS SUPT OF BUILDING
LOCALITY '
NEAREST
FOR APPLICANT TO FILL IN CROSS 5T
LEGAL
DESCRIPTION LOT NO G'rGle J O OWNER Milton Bade
MAIL
BLOCK TRACT ADDRESS 20 Birchcroft
NO OF BLDGS
SIZE OF LOT , t NOW ON LOT 1 CITYArcadia TEL NO
USE OF DISTRICT NO GROUP MAP PROCESSED BY
BUILDINGS
r BK PG
CONTRACTOR Square Deal Sewer Servlc ,5-(J,f �Y :i 79 �.►2i^/!/l��Cll�.
ADDRESS 2933 Maxson Rd.I'I'4 n n STATION CONNECTION DATA
CITY E1 Mente TEL NO 44 -2020 / DEPTH /
STATE 1288 O CLASS C-4 MANHOLE REFERENCE `.1�
LICENSE NO ` 7
NO DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y CURB P L M L TO P L d
1 PUBLIC SEWER @ $5 00 00
SEPTIC TANK SEEPAGE PIT OR a P C NO O
PITS AN DRAINFIELD @ $1000 CO IMP NO V JOB NO V
///,,, /
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO� //_ O
PRIVATE DISPOSAL SYSTEM @ S300 � 4
CONNECT ADDITIONAL BLDG OR AFFIDAVIT w VE■ EASEMENT RECORD INSTR NO DATE 0
WORK TO HOUSE SEWER @ $3 00 V
OVERFLOW SEEPAGE PIT DRAINFIELD d
EXTN CESSPOOLDRYWELL MANHOLE @ $500
ALTER REPAIR OR ABANDON HOUSEHWY OR ST WIDENING h
SEWER OR DISPOSAL SYSTEM @ $300 STATE ENCROACHMENT Z
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT 2 00
AUTHORIZATION TOTAL FEE 1 7 00 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 DA E INS TORS SIG AT E
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT_
CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS SEPTIC TANK SEEP PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
LICENSED AS REQUIRED BY LOS,ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWN E OF AND INTEND TO DISCONNECT PLUG AND
RESIDE IN THE ABOVE DESCRIBED RESIDE IAL ROPERTY ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERMfTTE SEEP PITS) ❑ CESSPOOLS ❑
0VALIDATION JACK R ALLEN e
CK M O CASH SUPERVISING MECHANICAL ENGINEER
I kr'- 0 5 7 "fly 16 j u D 7 00l