HomeMy Public PortalAbout9102 EMPEROR AVE_Sewer__ 10.82
76A642D APPLICATION FOR PERMIT
78A 84
COUNTY OF LOS ANGELES SEWER SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A LAMBIE, County Engineer ADDRESS
WILLIAM A JENSEN Sup t of Building
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST
LEGAL
DESCRIPTION LOT NO OWNER
MAIL
BLOCK TRACT ADDRESS O /
NO OF BL GS
SIZE OF LOT [�1 JJ f� NOW ON LOT CITY TEL NO
OF
BUIELD I NGS wA,- ( co j -
DISTRICT NO I GROUP MAP PROCESSED BY
BK PG
CONTRACTOR _PA A ,715 e S-
?,/ L�
ADDRESS VIT) CONNECTION DATA
CITY TEL NO STATION DEPTH
P
STATE M ANHOLE REFERENCE
REGISTRATION NO COUNTY LOWER
NO DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y CURB M L TO P L O
PUBLIC SEWER @ S5 00 V
PC NO
SEPTIC TANK SEEPAGE PIT OR CO IMP NO JOB NO
PITS AND�OR DRAINFIELD @ $1000
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO
PRIVATE DISPOSAL SYSTEM @ 53 00
CONNECT ADDITIONAL BLDG OR AFFIDAVIT WAIVE, EASEMENT RECORD INSTR NO DATE
WORK TO HOUSE SEWER @ S300
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL MANHOLE @ $500
ALTERRE PAIR OR ABANDON HOUSE HWY OR ST WIDENING
SEWER OR DISPOSAL SYSTEM @ $300 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT $ 2 00 - CHARGES
AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NA ED CON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER APPROVALS DATE INSPECTOR S SIGNATURE
SIGNED THIS�yDAY OF 19_ ig
OWNER ORAIV
�y.� NEW HOUSE SEWER YQ'r
OWNERS AGENT AE/ CONNECT ADDITIONAL 1
BUILDING OR WORK
ADDRESS
SEPTIC TANK SEEP PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
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
LICENSED AS 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 TH DES D R DENTIAL PROPER Y ABANDON HOUSE SEWER
SIGNATURE _ BACKFILL SEPTIC TANKS ❑
OF PERMITTEE ��
SEEP PIT(S) ❑ CESSPOOLS ❑
/��ALIDATION ROBERT A WOOD
CK M O CASH SUPERVISING MECHANICAL ENGINEER
V o 2 8 6 3"1'20' NOV 2 2 1 O D 7,00-