HomeMy Public PortalAbout5757AGNES AVE_Sewer IF
DEPAR174ENT OF COUNTY ENGINEER
SEWER—SEWAGE DISPOSAL 1
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
WILLIAM J FOX, COUNTY ENGINEER BUILDING
ADDRESS
FOR APPLICANT TO FILL IN LOCALITYNG
ABUILDDDREISS� NEAREST� CROSSST WD !'C � /✓
LOCALITYIIV70�� DISTRICT NO SERIAL NO PERMIT NO c
NEAREST S �f/ A 3!-( U ,_s
CROSS ST
^/ �/ RECEIVED
'BY�` Ready for Inspection /�DATEISSUED
OWNER /1' ���� Gam/ 'A" /�+N %-_13 -.3
MAIL /�J�� USE 20NE OCCUPANCY BK MAP PG
ADDRESS V
At � �.ry
CITY TEL NO 3 �?au Q c,4 r+Y II
CONTRACTOR �� �7 ��� �� CO IMP NO
ADORES JOB NO
CITY 1 TEL NO A14 TRUNK PERMIT NO
REGISTRATION NO
COUNTY ROAD PERMIT NO 2,74 7
LEGAL
DESCRIPTION LOT NO STATE ENCROACHMEhLT
/Y�� + PERMIT NO
BLOCKTRACT �� �/7G INDUSTRIAL
WASTE APPROVAL ------gym
SIZE OF LOT NOW ON LOT CHARGES
'10e)'t lCl o NO OF BLDGS
USE OF
BUILDINGS �i � CONN ON CHARGE FEE
NO DESCRIPTION OF WORK Z FEE REIMBURSEME EE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $ 350 RECEIPT NO E' BY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1 00
01, CONNECT ADDITIONAL BLDG OR XCEPTION RECO'MFD
WORK TO HOUSE SEWER 1 00
ALTER OR REPAIR EXISTING NO I DATE Y
SEWER OR DISPOSAL SYSTEM 1 00
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1 00 CONNECTION DATA
SEPTIC TANK SEEPAGE
PTS AND/OR DRAINFIIELD T OR 200
CESSPOOL—DRYWELL STATION ��- DEPTH
SPECIAL CONDITIONS ONLY 200 77,3.3ve tuPPE�EFERENCE LOUR
TYPE OF CONNECTIO LENGTH FROM
OWNERS PERMIT $ 00 Y CURB P L M L TO P L 3/� _
AUTHORIZATION TOTAL FEE
1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTIAG APPROVALS INSPECTOR"SSIGNATURE DATE
DWELLING TO THE PUBLIC SEWER
SIGNED THIS 12 Y F NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT _ p_ BUILDING OR WORK
SEPTIC TANK SEEP
ADDRESSLy ./Xf�l - AND/OR DRAINFIELD IT(S)
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI CESSPOOL[] DRYWELL 0
CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER REPAIR SEWER OR
REGULATING PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND
DISCONNECT ABANDON HOPLUG PLUGAND
AND STATE OF CALIFORNIA OR THAT I A HE LEGAL OWN
USE SEWER
ER OF THE ABOVE D IBED ASID L PRO RTY BACKFILL SEPTIC TANKS
T
cIGNATUREf//I SEEP PIS)� CESSPOOLS
SOF v
PERM _
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