HomeMy Public PortalAbout5118AGNES AVE_Sewer (2) Z �-
6A642D 62
7APPLICATION FOR PERMIT
6A842
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A LAMBIE COUNTY ENGINEER ADDRESS
COLEMAN W JENKINS SUP T OF BUILDING 14
LOCALITY
NEAREST ,/
FOR APPLICANT TO FII.L IN CRDBS STge
LEGAL D
DESCRIPTION LOT NO [l'� Q '� OWNER
MAIL
BLOCK TRACT ADDRESS
NO OF BL GS GN V b �,&EL NO 8
SIZE OF LOT NOW ON LOT CITY �/YY'Y
USE OF /
BUILDINGS DISTRICT NO GROUP MAP PROCESSED BY
BK
CONTRACTOR ��
ADDRESS i CONNECTION DATA
CITY TEL NO / STATION DEPTH J� /
UPP
STATE7 LIC MANHOLE REF ENCE
LICENSE NO 19 J CLASS D LOWER
NO DESCRIPTION OF WORK FEE TYPE OF eONINE&ION LENGTH FROM (�
HOUSE SEWER CONNECTING TO Y CURB P L M L TO P L SLY d
PUBLIC SEWER @ E5 00 O
SEPTIC TANK SEEPAGE PIT OR P C NO
PITS AND/OR DRAINFIELD @ il0 00 CO IMP NO 450 JOB NO /] V
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO �/ /�
PRIVATE DISPOSAL SYSTEM @ S300 / O
CONNECT ADDITIONAL BLDG OR AFFIDAVIT I WAIVER EASEMENT RECORD INSTR NO DATE
WORK TO HOUSE SEWER @ $300Lu
V
OVERFLOW SEEPAGE PIT DRAINFIELD CL
EXTN CESSPOOL DRYWELL MANHOLE @ $5 00 0.
N
ALTER REPAIR OR ABANDON HOUSE
HWY OR ST WIDENING
SEWER OR DISPOSAL SYSTEM @ $300 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT g c s
AUTHORIZATION TOTAL FEE 0Q CONNECTION CHARGE FEE I
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS
TO THE PUBLIC SEWER DATE INSPECTOR S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT_ CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
SEPTIC TANKSEEP 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 ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
LICE
NSEDAS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF AND INTEND TO DISCONNECT PLUG AND
RESIDE IN THE ABOVE DESCRIBED RESIDENTIAL PROPERTY ABANDON HOUSE SEWER
SIGNATURE ��� ❑
OF PER M}TTEE BACKFILL SEPTIC TANKS
SEEP PIT(S) ❑ CESSPOOLS ❑
VALIDATION JACK R ALLEN
SUPERVISING MECHANICAL ENGINEER
CK M O CASH
[Ar, 9b0 ..0-\0 APR29 D 25Cjg, 4