HomeMy Public PortalAbout5028AGNES AVE_Sewer (4) 0
82
76A64262
APPLICATION FOR PERMI
6A842
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDINGer Neu
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JOHN A LAMBIE COUNTY ENGINEER ADDRESS
COLEMAN W JENKINS SUP T OF BUILDING LOCALITY \_
NEAREST
FOR APPLICANT TO FILL IN CROSS ST
LEGAL
DESCRIPTION LOT NO OWNER
MAIL
BLOCK TRACT aG ADDRESS
NO OF BLLC
�) 'q
SIZE OF LOT NOW ON LOT �{j� CITY TEL NO
USE OF DISTRICT NO GROUP MAP PROCESSED BY
BUILDINGS
�'jBK PG//'
CONTRACTOR � E-_
;7/
2&
ADDRESS a CONNECTION DATA
CITY / , TEL NO STATION DEPTH t
STATE LIC R
MANHOLE REFERENCE UPPE
LICENSE NO CLASS J
NO DESCRIPTION OF WORK FEE TYPE OF CONNECTION LE G H PIOM
HOUSE SEWER CONNECTING TO Y CURB P L M L TOP C
PUBLIC SEWER $5 00
PC NO Q
SEPTIC TANK SEEPAGE PIT OR CO IMP NO JOB NO V
PITS AND/OR DRAINFIELD @ $1000
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO
PRIVATE DISPOSAL SYSTEM @ $300 O
CONNECT ADDITIONAL BLDG OR AFFIDAVIT I wAIVEII I EASeMENT RECORD INSTR NO DATE F"
WORK TO HOUSE SEWER @ S300 u
OVERFLOW SEEPAGE PIT DRAINFIELD a
EXTN CESSPOOL DRYWELL MANHOLE @ E5 00 to
ABANDON HOUSE HWY OR ST WIDENING 7
SEWER-6�8WL SYSTEM $3 00 STATE ENCROACHMENT L
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNER S PERMIT S z o0
AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEE
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTOR TO Co
CT THE ABOVE DESCR D E%IST ING DWELLING
TO THE PUBLIC APPROVALS DATE INSPECTOR S SIGNATURE
SIGNED THIS DAY OF 1_T
OWNER OR NEW HOUSE SEWER
OWNERS AGENT
CONNECTADDITIONAL
BUILDING OR WORK
ADDRESS
SEPTIC TANK SEEP PIT(S)
I HEREBY ACKNOWLEDGE THAT 1 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 ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
LICENSED AS REOUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM lei
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF AND INTEND TO DISCONNECT PLUG AND S
RESIDE IN THE ABOV ESCRIBED RESIDENTIAL PROPERTY ABANDON HOUSE SEW ER L
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PERM?7TEE y SEEP PIT IS) ❑ CESSPOOLS ❑
VALIDATION JACK R ALLEN
SUPERVISING MECHANICAL ENGINEER
CK M O CASH
1 Ar- 8 6 3 e' Ifsi►ft 17 L D 5 G