HomeMy Public PortalAbout5234AGNES AVE_Sewer r
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76 o 4 APPLICATION 'FOR PERMIT
76A 6
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING r
JOHN A LAMBIE COUNTY ENGINEER ADDRESS-5 ��- �J Y
COLEMAN W JENKINS SUP T OF BUILDING ,
LOCALITY
FOR APPLICANT TO FILL IN NEAREST
CROSS ST
(PRINT OR TYPE ONLY) hj/�
LEGAL V��
DESCRIPTION LOT NO !�� b OWNER V _
/► MAIL
BLOCK TRACT p-/1 ADDRESS
' NO OF BLDG5 I s " x
SIZE OF LOT NOW ON LOT CITY TEL NO
USE OF
BUILDINGS } } DISTRICT NO GROUP CLASS MAP PROCESSED B)
B K P
CONTRACTOR � � �� � -2 a �'
ADDRESS 3 CONNECTION DATA
CITY J `8< NO STATION DEPTH
STATE LIC t ✓` UPPER
LICENSE NO 6,5 / CLASS / FIANHOLE REFERENCE _ LOWER
NO DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y CURB P L M L TOP L
PUBLIC SEWER @ $5 00 PC NO
SEPTIC FANK SEEPAGE PIT OR 'r JOB NO )
PITS AND/OR DRAINFIELD @ 310_00 CO IMP NO
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO
PRIVATE DISPOSAL SYSTEM 33 00 0
CONNECTAammummom==0 ESI EASEMENT RECORD INSTR NO' DATE u
WORK TO HOUSE SEWER $300 f,
OVERFLOW SEEPAGE PIT DRAINFIELD d'
EXTN CESSPOOL DRYWELL MANHOLE @ $500 Q
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING /1
SEWER OR DISPOSAL SYSTEM 33 00 ~
STATE ENCROACHMENT I U
( _ PERMIT NO per,
_ INDUSTRIAL T 1�
WASTE APPROVAL .
- _
OWNERS' CHARGES
PERMIT S o0 -
AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEE - -
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBUR-EMENT FEE o
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING -
TO THE PUBLIC SEWER APPROVALS '� DATE INSPECTORS SIGNATURE
SIGNED THIS DAY OF - _ 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT 1 _ - y
_ - - CONNECT ADDITIONAL / f
BUILDING OR WORK G
ADDRESS SEPTIC TANKSEEP PIT(S) F
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION ANO/OR DRAINFIELD r
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY _ _
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYW ELL ❑Q
r I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER&R
LICENSED AS REQUIRED BY LOS GLES OUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE GAL O ER OF AND INTEND TO DISCONNECT PLUG AND I }
RESIDE IN THE ABOVE DESCRI D REST NTIAL P PERTY ABANDON HOUSE SEWER
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SIGNATURE BACKFILL SEPTIC TANKS ❑ T
OF PER MTTT EE SEEP PIT(S) Q CESSPOOLS ❑Q
ALIDATION - JACK R ALLEN e t
c ? M o cnsH SUPERVISING MECHANICAL ENGINEER
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