HomeMy Public PortalAbout9035 EMPEROR AVE_Sewer__ E-6D
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69 17-SS U�7 A PICAT�ON FOR PERMIT
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DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL
Department of County Engineer
County of Los Angeles BUILDING
JOHN A. LAMBIE, COUNTY ENfA
GINEER ADDRESS
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® CASSATT D. GRIFFIN, SDP'T OF BUILDING LOCALITYa'�
F RAPP LICA cesssToI .
LEGAL
DESCRIPTION LOT NO. OWNER
MAIL
BLOCK TRAC- ADDRESS ,B
O. OF BLDGS.
SIZE OF LOT � f. �' NOW ON LOT CITY n Z� Y`/P Z TEL. NO.
USE OF -
BUILDINGS •`' DISTRICT NO. GROUP MAP
�-G (�J
_ BK PG�
CONTRACTOR
r* CONNECTION DATA
ADDRESS �/� �O j•�
CITY -- TEL. NO. STATION !Y `6 DEPTH
MANHOLE REFERENCE 1 UPPER
TATE
REGISTRATION NO. 6/v g-�' ❑ COUNTY
' NO. DESCRIPTION OF WORK FEE
- TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO - Y. CURB P.L: ; M.L. TO P.L.
PUBLIC SEWER @ $
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT, DRAINFIELDP. C. N0.
EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $2.00 �•_CO. IMP. NO� JOB NO.
HOUSE SEWER CONNECTING TO r
PRIVATE DISPOSAL SYSTEM @ $1.00 ^_TRUNK PERMIT NO. ROAD PERMIT NO.
CONNECT ADDITIONAL BLDG.OR STATE ENCROACHMENT
WORK TO HOUSE SEWER @ $1.00 PERMIT NO. V
ALTER,REPAIR OR ABANDON HOUSE A ✓+ INDUSTRIAL _
r SEWER OR DISPOSAL SYSTEM @ $1.00 G WASTE APPROVAL
_ .re
CHARGES
o CONNECTION CHARGE FEE
OWNER'S PERMIT g 00
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
G
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- - APPROVALS DATE INSPECTOR'S SIGNATURE
TRACTOR, TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING ���,•
TO THE PUBLICSEWER.'t� NEW HOUSE SEWER
_- SIGNED THIS 'DAY OF 19 CONNECT ADDITIONAL
` OWNER OR j ., BUILDING OR WORK
OWNERS AGEN - SEPTIC TANK,SEEP,PITS) _
ADDRESS -� AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE TH& I HAVE EAD THI 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 AN
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE D
OF ABANDON HOUSE SEW
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE
DESCRIBEDRESIDENTIA P PERTY. BACKFILL SEPTIC TANKS
SIGNATURE i SEEP.PIT(S) ❑ CESSPOOLSsj w/`j
OF PERMITTEE
JOHN A. LAMB . COUNTY ENGINEER VALID0. ROBERT A. WOOD, CHIEF PLBG. INSPECTOR
CK. M. 0: CASH '
t d 7 g 1 0 A . 6.00 "
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