HomeMy Public PortalAbout9032 EMPEROR AVE_Sewer__ ' 648 312Y ■4 ALICATION , FOR PERMIT �� °�-�
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DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL
Department of County Engineer, �^y
' County of Los Angeles BUILDING
WM J. FOX. COUNTY ENGINEER ADDRESS
CASSATT D. GRIFFIN, SUP T OF BUILDING LOCALITY
FOR APPLICANT TO FILL IN NEAREST
CROSS ST
LEGAL - ♦- / /"
DESCRIPTION N lY OWNER /7
BLOCK TRACT D^ MAIL }
ADDRESS �V'V/�Y/ O
NO OF BLDGS
SIZE OF LOT/4) NOW ON LOT CITY TEL NO
USE OF
BUILDINGSDISTRICT NO I GROUP I MAP
I-' BK PG
CONTRACTO ,
� ! .-►
��./
ADDRESS CONNECTION DATA
CITY TEL e'� STATION r�y DEPTH ♦�
�^ ❑ STATE j M OLE REFERENCE
REGISTRATION NO �-!�S Jca ❑ COUNTY ♦ PPER
TYPE OF CONNECT N`�� LENGTH FROM
NO DESCRIPTION OF WORK FEE Y CURB P L' M L TO P L
HOUSE SEWER CONNECTING TO t
PUBLIC SEWER Q $ 3 50
HOUSE SEWER CONNECTING TO
_ PRIVATE DISPOSAL SYSTEM 1 00 _
CONNECT ADDITIONAL BLDG OR CO IMP NO ��� (,) JOB NO
WORK TO HOUSE SEWER 1 00
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM 1 00 TRUNK PERMIT NO ROAD PERMIT NO
DISCONNECT AND ABANDON 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
O •S PERMIT
CONNECTION CHARGE FEE/'
$ 1 00 I'll,
AUTHORIZATIONTOTAL FEEFa REIMBURSEMENT FEE
d-&-e-4
I HAVE THIS DATE CONTRACTED TH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE D SCRIBE EXISTING DWELLING APPROVALS DATE INSPECTOR S SIGNATURE
TO THE PUBLIC S VL
SIGNED THIS D Y 0 19j� NEW HOUSE SEWER
OWNER CrCONNECT ADDITIONAL
OWNERS AE - '_e BUILDING OR WORK
SEPTIC TANK, SEEP, PIT(S)
ADDRESS AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER, REPAIR, SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
I HEREBY 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 I AM THE LEG L OWNER OF THE ABOVE
DESCRIBED RESIDENTIAL PROP RTY. BACKFILL SEPTIC TANKS[ISIGNATURE I' SEEP PITS) (3 CESSPOOLS
'OF PERMITTEE �
WILLIAM J. FOX,COUNTY ENGINEER VALIDATION '
BY a 1W 5 g 9 2 IR x--19 4 f 4.5 D in
DEPUTY c //, T DEPUTY
BY BY
® DEPUTY DEPUTY
76A,6642D-CE806-10-71
APPLICATION ERMIT
COUNTY OF LOS ANGELES SEWER— WAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING �D }� IEIO 7 �ti
ADDRESS /�`� /r[
LOCALITY �/'(PL L/
NEAREST
FOR APPLICANT TO FILL IN CROSS ST
LEGAL �� T
DESCRIPTION LOT NO /��'//� Q OWNER 6
�o �/O / MAIL o E✓g2 a JQ .
BLOCK TRACT ADDRESS .7
NO F
SIZE OF LOT 51) X 11 `-J'v NOWOON LOTS CITY TEL NO OZO`��� X
USE OF
BUILDt NGS DISTRICT NO I GROUP K p3 MAP CESSED BY
B
CONTRACTOR �rV�
ADDRESS I A CONNECTION DATA
CITY TEL NO STATION DEPTH
STATE LIC UPPER
LICENSE NO CLASS MA HOLE REFERENCE LOWER
NO DESCRIPTION OF WORK FEE ITYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y CURB PL ML TOP L
PUBLIC SEWER 0 $7 00
PC NO
SEPTIC TANK SEEPAGE PIT OR
PITS AND/OR DRAINFIELD STOOD CO IM NO JOB NO
HOUSE SEWER CONNECTING TO TRUNK PER O ROAD PERMIT NO d
PRIVATE DISPOSAL SYSTEM @ 5300 O
CONNECT ADDITIONAL AFFIDAVIT WAIVIII IAS RECORD INSTR NO DATE 0
WORK TO HOUSE SEWER @ $30 ^�
OVERFLOW SEEPAGE PIT DRAINFIELD p�
EXTN CESSPOOL DRYWELL @ $500 HWY OR ST WIDENING O
ALTER REPAIR OR ABANDON HOUSE V
SEWER OR DISPOSAL SYSTEM 0 $300 STATE ENCROACHMENT t!J
MANHOLE $7 00 PERMIT NO d
INDUSTRIAL to
WASTE APPROVAL Z_
OWNER'S PERMIT 0 s JW'- CHARGES
CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE U
I HAVE 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
ADDRESS BUILDING OR WORK
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION SEPTIC TANK SEEP PIT(S)
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY AND/OR DRAINFIELD
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
LICENSEDAS 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 BACKFILL SEPTIC TANKS Cl
OF PERMITTEE SEEP PIT(S) ❑ CESSPOOLS ❑
VALIDATION QqK M 0 CASH
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