HomeMy Public PortalAbout5210AGNES AVE_Sewer C4.
9&EQ63 S 9S PERMITAPPLICATION FOR PERMIT
1
8&H 6
DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL.
Deportment of County Engineer
County Of L08 Angeles 'LDIBU
ADDRESSG _10 IU
WM J FOX COUNTY ENGINEER
CASSATT D GRIFFIN SUP T OF BUILDING LOCALITY C.
FOR APPLICANT TO FILL IN NEAREST
_CROSS ST �L�(JA/lJ
LEGAL
DESCRIPTION LOT NO OWNER L�,N
BLOCK TRACT / 1,z 6 O MAIL
ADDRESS
NO
SIZE OF LOT� x z V NOWOON LOTS CITY T
� TEL NO
USE OF
BUILDINGS DISTRICT NO I GROUP ( MAP
BK PG
CONTRACTOR C Poo L �+
ADDRESS o CONNECTION DATA
CITY C TEL NO STATI DEPTH
❑ STATE MANHOL11CFERENCE UPPER
REGISTRATION NO ❑ COUNTY LOWER
NO DESCRIPTION OF WORK FEE
TYPE OF C'hVNECTION LP<GTH -ROM
HOUSE SEWER CONNECTING TO Y CURB P L i L TO P L
PUBLIC SEWER Q $ 3 50
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 100 _
CONNECT ADDITIONAL BLDG OR P C NO
WORK TO HOUSE SEWER 1 00 CO IMP NO JOB NO
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM 1 00 TRUNK PERMIT NO ROAD PERMIT NO
DISCONNECT AND ABANDON SEWER STATE ENCROA MENT
AND/OR DISPOSAL SYSTEM 1 00 PERMIT NO
SEPTIC TANY SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 00 INDUSTRIA
/ CESSPOOL DRYWELL �� WASTE AP OVAL
SPECIAL CONDITIONS ONLY 200 CHARGES
OWNERS I PERMITi 00 CON ECTION CHARGE FEE
S
AUTHORIZATION I TOTAL FEE S a REIMBURSEMENT FEE
TRACTOR TTOSCONNECT OTHEAABOVECTED WDESCRIBEDITH THE HEXISTINGADWELL11NG APPROVALS DATE INSPECTOR SSIGNATURE
TO ThE PUBLIC SE ER
NEW HOUSE SEWER
SIGNED Tf DAY 0 19. 12
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
SEPTIC TANK SEEP PIT(S) `
ADDRESS AND/OR DRAINFIELD �
I HEREBY ACKN LEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL[IDRYWELL
ANSTATE THAT HE
D ABOVE IS CORRECT AND AGREE TO COMPLY 1
WITH ALL COUNTY ORDINANCES AND STATC LAWS REGULATING ALTER REPAIR SEWER R _d
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM �* °
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR
LICENSED AS REQUIRED BY L ANGELE AND STATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT I OF THE ABOVE ABANDON HOUSE SEWER
DESCRIBED RESIDENTIAL BACKFILL SEPTIC TANKS❑
SEEP PIT(S) CESSPOOLS❑
SIGNATURE
OF PERMITTEE
WILLIAM J FOX COUNTY ENGINEER VALIDATION R A WOOD CHIEF PLBG INSPECTOR
41P.8307jug 17 4 3 0 0 1�
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