HomeMy Public PortalAbout9109 EMPEROR AVE_Sewer__ D
S&fi6633 88 APPLICATION FOR PERMIT 1
DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE D I S POSA L
Department of County Engineer
County of LOS Angeles BUILDING
WM.J. FOX. COUNTY ENGINEER ADDRESS (/
CASSATT D. GRIFFIN, SUPT OR BUILDING LOCALITY
FOR APPLICANT TO F IN CROSS ST / f9
LEGL
DESCRIPTION LOT NO OW NES^ /
BLOCK TRACT i MAIL
ADDRESS
NO OF BLDGS
SIZE OF LOT NOW ON LOT CITY TEL NO
USE OF �• _
BUILDINGS J DISTRICT NO
GROUP BK MAP
PG
CONTR & 6 ,� GNS VI
r
ADDRESS -�`- /f/�,D G••J/,p/l��" CONNECTION DATA V
��,�� TEL N� /� �— STATION C7 DEPTH
/ ❑ UPPER STATE MANHOLE REFERENCE�DO � LAB
REGISTRATION NO !� ❑ COUNTY
NO DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO TYPE OF CONNECTION LENGTH FROM ✓
PUBLIC SEWER Q $ 3 50 - Ctl�9" P L M L TO P L .J
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1 00 _
CONNECT ADDITIONAL BLDG OR P C NO
WORK TO HOUSE SEWER 1 00 CO IMP NO O JOB NO
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 DPAINFIELD 2 00 INDUSTRIAL
CESSPOOL-DRYWELL WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2 00 CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT $ 1 00
AUTHORIZATION I TOTAL FEE REIMBURSEMENT FEEIHINE
TTOS DATE CONNECT THECTED ABOVEWITH THE DESCR DESCRIBED EXEITINGpMED DWELLINGCON-
TRACTOR APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC S�EWJE/A. ,,e{
SIGNED THI '-DAY OFL� '' t �j NEW HOUSE SEWER
OWNER 0 CONNECT ADDITIONAL
OWNERS NT BUILDING OR WORK
SEPTIC ,SEP
ADDRESS � hd AND/ORTANKDRAINFEELDPIT(S)
IO ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL Cl
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
IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND
CALIFORNIA OR HAT 1 AM THE LEGAL OW F THE ABOVE/ ABANDON HOUSE SEWER
DESCRIBED R �INT;A& PR RTY BACKFILL SEPTIC TANKS❑ �,.,/
�' SEEP PIT(S) ❑ CESSPOOLS pjl " 1
SIGNA
i'R TE
J.FOX.COUNTY ENGIN VALIDATION R.A.WOOD, CHIEF PL.BG. INSPECTOR
N>�
Co 9 1 3 E 0f',i 18 4 4.5 0