HomeMy Public PortalAbout9081 EMPEROR AVE_Sewer__ S E•8E-6D63 11-55
6 APPLICATION FOR PERMIT 1
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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 ENGINEER ADDRESS >w�
® CASSATT D. GRIFFIN, SUPT of BUILDING LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL OWNER
DESCRIPTION LOT N0.
MAIL
BLOCK TRACT A t_ v ADDRESS
(� CITY TEL. NO.NO. OF BLDGS. /
SIZE OF LOT-5,&-Y/9 NOW ON LOT /
USE OF DISTRICT N0. GROUP MAP
BUILDINGS � ��� � I � BK � PG�
CONTRACTOR -r ✓'
�- CONNECTION DATA
* ADDRESS C
STATION `,�,� DEPTH
TEL. N0.
CI Y .�
- MANHOLE REFERENCE 7� �j ® b
j� � [3 STATE f ObY � LOWER
REGISTRA ION NO. L , 'j ❑ COUNTY
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO ,.� s, TYPE OF CONNECTION LENGTH FROM �1
PUBLIC SEWER @ $3.50 �- M.L.TO P.L.
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT, DRAINFIELD P. C. N0.
EXTN..CESS POOL,DRYWELL,MANHOLE @.$2.00 CO. IMP. N0. JOB NO.
HOUSE SEWER CONNECTING TO _
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.
• ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
- SEWER OR DISPOSAL SYSTEM @ $1.00 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT00
AUTHORIZATION TOTAL FEE $ ' ' j� REIMBURSEMENT FEE �af
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 PUBLIC SEWER. NEW HOUSE SEWER
SIGNED THIS DAY OF 19 s CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK
OWNERS AGENT SEPTIC TANK,SEEP, PIT(S)
ADDRESS
A AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I 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 EGAL OWNER OF THE ABOVE
DESCRIBED RESIDE L UOPERT BACKFILL SEPTIC TANKS❑
SEEP. PIT(S) ❑ CESSPOOLS❑
SIGNATURE -
OF PERMITTE
JOHN A. LAMBIE, COUNTY ENGINEER VALIDATION ROBERT A. WOOD, CHIEF PLBG. INSPECTOR
CK. H.
1 6 n zll 6 44.5 0 to