HomeMy Public PortalAbout9123 EMPEROR AVE_Sewer__ D
6&E 6631254 o APPLICATION FOR PERMIT
1`6&E 6
DMSION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL
Department of County Engineer
County of Los Angeles BUILDIN
WM J FOX, COUNTY ENGINEER ADDRESS
CA66ATT D GRIFFIN, SUPT OF BUILDINGj=J LOCALITY
:I.c i / / .1 -,
FOR APPLICANT TO FILL IN NEAREST
CROSS ST !✓ �' �—^�Z+`
LEGAL
DESCRIPTION LOT NO / J OWNER
BLOCK TRACT J / U MAIL �,c...
A.
��DDRE SNO OF BLDGS . ISIZE OF LOT NOW ON LOT T {.!r TEL I .d,�
USE OF -
BUILDINGS �y DISTRICT ( GROUP I MAP
BK PG
CONTRACTOR
ADDRESSf� L / �}C ! CONNECTION DATA / ffT—
CITY TEL + \� STATION lP f, (D. ,i DEPTH (p
ESTATE MANHOLE REFERENC 1/..�!'4CJ P W LOWER
REGISTRATION NO �/ E] COUNTY COUNTY _ �
TYPE OF CONNECTI LENGTH FROM
NO DESCRIPTION OF WORK FEE Y CURB rP L 11 M L TO P L ^� ,
HOUSE SEWER CONNECTING TO J�
PUBLIC SEWER Q $ "3 50 V
HOUSE SEWER CONNECTING TO
_ PRIVATE DISPOSAL SYSTEM 1 00
CONNECT ADDITIONAL BLDG OR CO IMP NO JOB NO
_ WORK TO HOUSE SEWER 1 00 _
'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 DRAINFIELD 2 00 INDUSTR'AL
CESSPOOL- DRYWELL WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2 00 CHAR
CONNECTION CHARGE FEE
OWNER'S PERMIT $ 1 00
AUTHORIZATION TOTAL FEE "~� REIMBURSEMENT FEE , ,(
TRACTORHAVE T TO CON ECTHIS DATE ONTRTHEA ABOVE DESCRIBED EXISCTED WITH THE TIINGNAMED
DWELLIING APPROVALS DATE INSPECTOR S SIGNATURE
TO THE PUBLIC ER N HOUSE SEWERL.i��r
SIGNED THIS -DA cG+F 19-6-: v F� Pr
OWNEROR CONNECT ADDITIONAL
OWNERSGEN BUILDING OR WORK
ASEPTIC SEP,
DDRE r z AND/ORTANK DRAINFEELD PIT(S)
I HEREBY ACKNOWLEDGE THAT I H READ THIS APPLICATION CESSPOOL[IDRYWELL ClAND 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 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF
CALIFORNIA OR THAT I AM 4HE LEGAL-OWNER OF THE ABOVE ABANDON HOUSE SEWER
DESCRIBED RESIDENTI7PTY BACKFILL SEPTIC TANKS❑
EP PIT(S) ❑ CESSPOOLS ,� O! &I
SIGNATURE ..
OF PERMITTE
WILLIAM J. FOX.COUNTY ENGINEER VALWATION
Aro l 6 9 8 .� SEP g 4 4.J 0 �
BY _.
DEPUTY DEPUTY
BY BY
,-® DEPUTY DEPUTY