HomeMy Public PortalAbout9126 EMPEROR AVE_Sewer__ 4yv c o
176A642D �
CE 808(REV 6/781 APPLICATION'FOR PERMIT
os SEWER - SEWAGE DISPOSAL
COUNTY OF LOS ANGELES BUILDING-AND SAFETY
FOR APPLICANT TO FILL IN DISTRICT NO I GROUP MAP BY
BUILDINGADDRESS 9126 E. Emperor • ` U 3 ,_PROCESS
LOCALITY San Gabriel CONNECTION DAT ;
NEAREST
STATION - 1 DEPTH I '
CROSS ST
UPPER
MANHOLE REFERENCE _ LOWER
OWNER Godleyn i TYPE OF CONNECTION LENGTH FROM r
MAIL
ADDRESS 9126 E. Emperor Y CURB P L, MIL TO P L r
1 � P C NO 11� , I
CITY San Gabrie-&L NO 287-9425 CO IMP NO JOB NO
LEGAL TRUNK PERMIT NO ROAD PERMIT NO
DESCRIPTION LOT NO J
AFFIDAVIT I WAIVER I EASEMENT RECORD INSTR NO DATE
BLOCK TRACT
NO OF BLDGS
SIZE OF LOT NOW ON LOT HWY OR ST WIDENING
USE OF
BUILDINGS resid. STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
CONTRACTOR
Universal Plumbing WASTE APPROVAL
ADDRESS 2631 Lee Ave. CHARGES
CITY L NO CONNECTION CHARGE FEE
460
STATE I-Cp� REIMBURSEMENT FEE
LICENSE NO 16018 CLASSC 6CG20
NO DESCRIPTION OF WORK FEE APPROVALS DATE INSPECTOR S SIGNATURE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER
SEPTIC TANK SEEPAGE PIT OR NEW HOUSE SEWER
PITS AND/OR DRAINFIELD CONNECT ADDITIONAL '
HOUSE SEWER CONNECTING TO BUILDING OR WORK
PRIVATE DISPOSAL SYSTEM '
CONNECT ADDITIONAL BLDG OR SEPTIC TANK SEEP PIT(S) {q�
WORK TO HOUSE SEWER - AND/OR DRAINFIELD
OVERFLOW SEEPAGE PIT DRAINFIELD CESSPOOL
EXTN CESSPOOL DRYWELL MANHOLE [3 DRYWELL❑
ALTER REPAIR OR ABANDON HOUSE ALTER REPAIR SEWEROR
SEWER OR DISPOSAL SYSTEM SEWAGE DISPOSAL SYSTEM 1
" - DISCONNECT PLUG AND - -
ABANDON HOUSE SEWER
_ BACKFILL SEPTIC TANKS❑ - -
OWNER S Perm It s SEEP PITISI❑ CESSPOOLS -
❑ «
AUTHORIZATION TOTAL FEE' A VALIDATION
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON ✓V;/// G'L� ,
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING �D �J -7 YXrl -4 54 5 8 A
TOTHE PUBLIC SEWER , I / g U�
SIGNED THIS DAY OF '- 19_ - #'o 050 O ' O
OWNER OR
OWNERS AGENT _ _ 2 0 0 1 /�, 0 0" 4
ADDRESS •a V
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION O-O O 1 Lo 0.6
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING 2 (l
PLUMBING AND SEWERS - - 071
'!7+ 1 3 9
1 HEREBY CERTIFY THAT I PROPERLY REGISTERED AND/OR
LICENSED AS REQUIRED BY ANGELES COUNTY AND STATE OF
CALIFORNIA OR THAT I AM T EG AL OWN OF AND INTEND TO RE
SIDE IN THE ABOVE DESC D RESIDEN PROPERTY
SIGNATURE - - - --OF PERMI EE
I
7DA
E 66 ■A L,ICATION FOR ■ ERMI ■
1
s& ®DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE ISPOSAL
Department of County Engineer
County of Los Angeles BUILDING
WM.J. FOX, COUNTY ENGINEER ADDRESS
CASSATT D GRIFFIN,SUPT OR BUILDING LOCALIT
NEAREST
FOR APPLICANT TO FII AN CROSS ST
LEGAL �--
-DESCRIPTION LOT NO tom" OWNER
/ MAIL
BLOCK TRACT f ADDRESS
NO OF BLDGS
SIZE OF LOT /' NOW ON LOT CITY TEL NO
USE OF 0
BUILDINGS i DISTRICT NO GROUP MAP
`1 BK PG
CONTRL&y - �� ', •'� / .-/ C! � �r���
ADD ® A ,-A, .j�,/,,,G� �� CONNECTION DATA
CEL NO ' '' STATION tl
DEPTH
,,//�� ❑ STATE MANHOLE REFERENCE
REGISTRAT ON NO r/� ❑ COUNTY ^� LOWER
r NO DESCRIPTION OF WORK FEE TYPE OF CONNECT( LENGTH FROM f
HOUSE SEWER CONNECTING TO Y CURB P L M L TOP L
PUBLIC SEWER Q $ 3 50
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 100 _
CONNECT ADDITIONAL BLDG OR fj /
WCRK TO HOUSE SEWER 100 CO IMP NO 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 DRAINFIELD 00 INDUSTRIAL
CESSPOOL- DRYWELL WASTE APPROVAL
SPECIAL CONDITIONS ONLY 200 CHARGES
PERMIT CONNECTION CHARGE FEE
OWNER'S S t Oo
AUTHORIZATION I TOTAL FEE - REIMBURSEMENT FEE
1 HAVE THIS DATE CONTRACTED WITH THE, HI iNAMED CON
TRACTOR TO CONNECT THE ABOVE DE �yR/( ED EXI ING DWELLING APPROVALS DATE INSPECTOR SSIGNATURE
TO THE PUBLIC SEW,2(i -'rG"
"�� NEW HOUSE SEWER
SIGNED THIS DA`-OF } �_ —1 ,
CONNECT ADDITIONAL
OWNER
OWNERS AGE - ?-' BUILDING OR WORK
ADDRESS �� (,r SEPTIC TANK, SEEP, PIT(S)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT IHAVE READ THIS APPLICATION CESSPOOL[IDRYWELL ElAND 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
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR
LICENSED AS REQUIRED BY LOS ANGELES CTY AND STATE OF DISCONNECT PLUG AND
DESCRIBED
CALIFORNIA
REOR THATS1DEtCT A 1 PRM PER AL�OW OF THE ABOVE ABANDON HOUSE SEWER
TANKS
SEEP BACKFILL SEPTIC
PIT(SCESSPOOLS
SIGNATURE !+
OF PERM
W1LLIAM OX.COUNTY ENGINEER VALIDATION R.A.WOOD, CHIEF PLBG. INSPECTOR
1 8 7 0A OCT30 4 4.5 U
L ✓��G