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HomeMy Public PortalAbout9117 EMPEROR AVE_Sewer__ r APPLICATION ®® p/�� c gp��� - ppq� PERMIT �ga� p��/y�pq 7 `, 6 h E•663 12.54 DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL Deportment of County Engineer County of Los Angeles BUILDING WM. J. FOX, COUNTY ENGINEER ADDRESS AJ' -- ' •• // CASSATT D. GRIFFIN,SUPT OF BUILDING LOCALITY FOR APPLICANT TO FILL IN "FOREST 1 CROSS ST.I LEGAL DESCRIPTIO LOT N fJ (il t rt OWNER BLOCK TRACT MAIL I ^ ADDRESS L —0 r♦ NO. OF BLDGS. _ B SIZE OF LOT Fo NOW ON LOT jJ ITY .�j .�I� EL. NO. USE OF �`-' Gds /� BUILDINGS ,..i✓^ �� �// DISTRICT O. GROUP MAP CONTRACTOR BK PG ADDRESSf� // CONNECTION DATA CITY // / , TEL. N0.L'��. � C( STATION -7 DEPTH t^-�—C ❑ STATE / MANHOLE REFERENCE REGISTRATION NO. 7 ❑ COUNTY UPPER LLL TYPE OF CONNE TION LENGTH FROM / No. DESCRIPTION OF WORK FEE Y. CURB L. M.L.TO P.L. HOUSE SEWER CONNECTING TO -0 PUBLIC SEWER @ $ 3.50 HOUSE SEWER CONNECTING TO ��-- PRIVATE DISPOSAL SYSTEM 1.00 fl CONNECT ADDITIONAL BLDG. OR T °. CO. IMP. NO. may` JOB. N0. . _ WORK TO HOUSE SEWER 1.00 �� ✓ Cq� 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 _ ITS AND/OR DRAINFIELD 2.00 INDUSTRIAL CESSPOOL- DRYWELL WASTE APPROVAL SPECIAL CONDITIONS ONLY 2.00 CH yG-ES CONNECTION CHARGE FEE OWNER'S PERMIT S 1 00 AUTHORIZATION TOTAL FEE 0 REIMBURSEMENT FEF 1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED CON- TR ON- {� TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE TO THE PUBL C SEWER SIGNED THIS DAY OF NEW HOUSE SEWER OWNER eR' CONNECT ADDITIONAL +^ OWNERS _ _ _ BUILDING OR WORK a SEPTIC TANK, SEEP, PIT(S) ADDRESS AND/OR DRAINFIELD I HEREBY ACKNOWLEDGE THAT 1 HAVE REAY THIS APPLICATION CESSPOOL❑ DRYWELL[3AND 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 REOUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER CALIFORNIA OR THAT I AM THE LEGAL-OWNER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS❑ yQ s R;• Q SEEP. PIT(S) ❑ CESSPOOLS�}., '�;/' 1^ � r 'lP%'�P,, SIGNATURE �� _14 OF PERMITTE � WILLIAM J. FOX, COUNTY ENGINEER VALIDATION BY BY DEPUTY /� DEPUTY (\ >f © DEPUTY DEPUTY �/�