HomeMy Public PortalAbout9114 EMPEROR AVE_Sewer__ '76A642D APPLICATION FOR PERMIT 1
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DMSION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Deportment of County Engineer
County of LOS Angeles BUILDING Q • B'9
WM.J. FOX, COUNTY ENGINEER
CASSATT D. GRIFFIN,SUPT OF BUILDING LOCALITY SA
FOR APPLICANT TO FILL IN NEAREST ) M
CROSS Si
—DESCLEGRIPTION LOT NO � � ' dr" �
��// OWNER
BLOCK TRACT A y' ! G MAIL
ADDRESSNO OF // A ♦ 0" tl tl,.i,
SIZE OF LOT /� NOW ON LOT ,�O" CITY�b- 4'j� TEL NO ®y�
USE OF �� .�f
BUILDINGS DISTRICT NO GROUP MAP
BK PG
CONTRACTOR ',`Tt /p --r
ADDRESS / CONNECTION DATA
CITY' TEL NO Av.0 tpl&e 4�PJ94y� STATION ` DEPTH
i / � ❑ STATE °� MANHOLE REFERENCE
REGISTRATION NO ❑ COUNTY ��f � UPPER
TYPE OF CONNECTION LENGTH FROM
NO DESCRIPTION OF WORK FEE X" P L M L TO P L
HOUSE SEWER CONNECTING TO 7
PUBLIC SEWER (S $ 3 50
HOUSE SEWER CONNECTING TO
_ I PRIVATE DISPOSAL SYSTEM 1 00
CONNECT ADDITIONAL BLDG OR CO IMP NO JOB NO
WORK TO HOUSE SEVER 1 00 111
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 SECPAGE PIT OR
PITS AND/OR DRAINFIELD 2 00 INDUSTRIAL
CESSPOOL- DRYWELL WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2 00 CHARGES
CONNECTION CHARGE FEE
OWNERS PERMIT $ 1 00
AUTHORIZATION I TOTAL FEE t -ro REIMBURSEMENT FEE
TRACTORHAVE T TOS CONNECT THE DATE ABOVE DESCRIBED EXISCTED WITH THE NINGNAMED
DrWELLING APPROVALS DATE INSPECTOR SSIGNATURE
TO THE PUBLIC SEWER _ � �J
SIGNED THIS DAY OF 19^ NEW HOUSE SEWER -18 6 ftejV_g
,OWNER OR /,— C i CONNECT ADDITIONAL rvr c�
OWNERS AGENT BUILDING OR WORK
SEPTIC ,ADDRESS-- AND/ORT DANKRAINFIELD PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL ElDRYWELL(jAND 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 ECT PLUG AND
NN
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT
N HOUSE SEWER
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIAL PROPERTY BACKFILL SEPTIC TANKS❑ �,..,( y
SEEP PIT(S) ElCESSPOOLS hLl '2r,17
SIGNATURE
60111
OF PERMITTEE
WILLIAM J. FOX, COUNTY ENGINEER VALIDATION
BY . .T06 60 2 4 SI �2 7 4 4.5 0
DEPUTY DEPUTY
1,
BY BY r f
° ® DEPUTY DEPUTY /"