HomeMy Public PortalAbout9111 EMPEROR AVE_Sewer__ CES08a-se APPLICATION' FOR �PEli'MIT�
esos COUNTY OF LOS ANGELES
SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMCounty Fmgineer ADDRESS
91U &per r Avenue.
CASSATY D. GRIFFIN. Supt of Buildag LOCALITY `�''�
NEAREST a� /)
FOR APPLICANT TO FILL IN - ceoss STLEGAL
•ter,= "''�
bESCRIPTION LOT NO .4 ' _OWNER Jack P. & Elsie S. ,Mendel o
BLOCK l�T.R,A,CT 11990 !!�� ° MAIL
ADDRESS 9111 Emperor Avenue
SIZE OF LOT 60x1 6 NOWNO OON LOTS vice CITY San Gabr
No AT. 7-1270
USE OF1 t,
BUILDINGS Dwelling DISTRICT NO GROUP BK MAP PG
`P-RROOCESSED BY
CONTRACTOR 1T ' /%L/
ADDRESS T-- CONNECTION DATA
CITY TEL NOA. STATION - � DEPTH
STATE MANHOLE REFERENCE PPERi
REGISTRATION NO B COUNTY
NO DESCRIPTION F WORK: FEE !n LOWER.
HOUSE SEWER CONNECTING TO
PUBLIC SEWER Q $8 00
SEPTIC TANK, SEEPAGE PIT OR TYPE OF CONNECTION LENGTH FROM
ITS AND/OR DRAINFIELD Q $S 00 Y CURB P L M L TOP L
OVERFLOW SEEPAGE PIT, DRAINFIELD -
EXTN CESSPOOL DRYWELL MANHOLE @ $2 00
HOUSE SEWER CONNECTING TO P C N0.
PRIVATE DISPOSAL SYSTEM @ $1 00 CO IMP.NO -�� JOB NO
CONNECT ADDITIONAL BLDG OR ` TRUNK PERMIT NO ROAD PERMIT NO
WORK TO HOUSE SEWER 40 $1 00
ALTER REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
SEWER OR DISPOSAL SYSTEM @ $1 00 PERMIT,NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNEWS PERMIT $ 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON APPROVAL$ D TE INSPECTO S S GNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED`EXISTING DWELLING
TO THE PUBLIC SEWER
SIGNED THIS AY OF May I 195-9— NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNFR (T j � � "— BUILDING OR WORK
SEPTIC TANK,'SEEP, PIT(S)
ADDRESS AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL❑ DRYWELL❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER, REPAIR SEWER OR
PLUMBING AND SEWERS - SEWAGE DISPOSAL SYSTEM
1ICHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER.
CALIFORNIA ,OR THAT I AM THE LEGAL_QWNER OF THE ABOVE
DESCRIBED RESIDE I PROPERTY. BACKFILL SEPTIC TANKS❑
SIGNATURE SEEP PITS ❑ CESSPOOLS
OF PERMIT"E - 4
mum
ROBERT A WOOD
OL H.o. 1/cAs� J SUPERVIfdING MECHANICAL ENGINEER
0 5 8 1 A4' 1 g 1 -0 A J.Cf Q
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