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Home My Public Portal About5739 AGNES AVE_Sewer__ D S&E 663 J2 54 APPLICATION FOR PERMIT 5&E 6 , 1 DMSION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL Deportment of County Engmeer �-3� �H* ,!0. ),yQs COU Of LOB 6 ADDRESS -/G _ WM J FOX COUNTYTY ENGINEER CASSATT D GRIFFIN SUP T OF BUILDING LOCALITY I FOR APPLICANT TO FILL IN CROSS ST l vp c9Q LEGAL DESCRIPTIO LOT NO OWNER �q Q I 11�M p,�.I/gp+eSf,el�1 BLOCK TRACTAIL 6 p DRESS SIZE OF LO �d / NOW ONBLOTS CITYIP jl�/�' (¢IIjt TEL NO USE OF 9/ P r BUILDINGS S�. ' DISTRICT Ab IUP MAP✓ CONTRA OR BK PG ADDRESS G' j •jamT //yam CONNECTION DATA CITY TEL NO h `� �L� ti STATION J�-i'�a, �7 DEPTH j t y ❑ STATE ? jy/ MAN OLE REFERENCE REGISTRATION NO � J ..,�� A9 ❑ COUNTY �Jl �I/c /LOWEE D TYP CURBVECTION LENGTH FROM / NO DESCRIPTION OF WORK FEE M L TO P L THOUSE SEWER CONNECTING TO O PUBLIC SEWER @ $ 3 50 HOUSE SEWER CONNECTING TO PRIVATE DISPOSAL SYSTEM 100 CONNECT ADDITIONAL BLDG OR CO IMP NO f 30 �? JOB NO _ WORK TO HOUSE SEWER 1 00 ALTER OR REPAIR EXISTING _ SEWER OR DISPOSAL SYSTEM 1 00 TRUNK PERMIT NO ROAD PERMIT NO DISLONNECT AND AB4NDON SEWER STATE ENCROACHMENT _ AND/OR DISPOSAL SYSTEM 1 00 PERMIT NO SEPTIC TANK SEEPAGE PIT OR _ PITS AND/OR DRAINFIELD 2 00 INDUSTRIAL CESSPOOL DRYWELL WASTE APPROVAL SPECIAL CONDITIONS ONLY 2 00 CHARGES CONNECTION CHARGE FEE OWNER S PERMIT g 1 400c0— AUTHORIZATION TOTAL FEE 0 REIMBURSEMENT FEE I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED CON APPROVALS DATE INS ECTOR S SIGNATURE TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING I TO THE PUBLIC SEVER p / p SIGNED THIS DAY OF, � 19 /` NEW HOUSE SEWER OWNER OR /y f/h /p CONNECT ADDITIONAL OWNERS AGE T -�Gi'b � j e� BUILDING OR WORK �� SEPTIC TANK SEEP PIT(S) ADDRESS4; / fd d 7 j� AND/OR DRAINFIELD I HEREBY ACKNOWLEDGE THAT HAVE READ TI-14APPLICATION CESSPOOL❑ DRY-WELLC3 STATE THAT THE ABOVE IS ORRECT AND AGREE TO COMPL WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWER OR - PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY BACKFILL SEPTIC TANKS❑ q 4 ♦ SEEP PITS) ❑ CESSPOOLS Er OI ��...Y1` �,•+- "'°"""�'� SIGNATURE OF PERMITTEE WILLIAM J FOX COUNTY ENGINEER VALIDATION � 22. 8 ?ZR JAN30 4 4.50 BY BY DEPUTY DEPUTY I BY BY �QO� ® DEPUTY I �PUTY/