HomeMy Public PortalAbout9147 EMPEROR AVE_Sewer__ 24650 INSERTS
GE606 6.60 APPLICATION FOR P 6. R IVI I
�6A6aan COUNTY OF LOS ANGELES 6 S�EWERo—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS `
. LIE, CountEineer
WIOLLIAM A.JENSEN, Supt ofnBuilding � `
LOCALITY— /
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
�--
LEGAL £i OWNER
DESCRIPTION LOT N0. ///���
BLOCK TRACT jj�/ MAIL
ADDRESS
Ndr.OF BLDGS.
SIZE OF LOT NOW ON LOT / ly.
ITY TEL. NO.
USE OF �� TRICT NO. GROUP MAP PROCESSED BY
BUILDINGS ��-'�l/J/'�
K PG
CONTRACTOR`SADDRES � , � CO CTION ATACITTEL.N0. TATION DEPTH
ANHOLE REFERENCE UREGISTRATION NO. �(p Q YNO. DESCRIPTION OF WORK FEE
PUBLICSE SEWER EWERCONNECTING TO@ $3.00TYPE OF CONNECTIO LENGTH FROM
PETS AND/OR DRAINFPTIC TANK, GEDIT OR @ $3.00 CURB P.L. M.L.TO P.L.
OVERFLOW SEEPAGE PIT. DRAINFIELD
EXTN..CESSPOOL. DRYWELL @ $2.00
HOUSE SEWER CONNECTING TO `�` P.C.NO.
PRIVATE DISPOSAL SYSTEM @ $1.00 CO.IMP. N0. � O JOB NO. y,
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT N0. ROAD PERMIT N0. O
WORK TO HOUSE SEWER @ $1.00 V
SEWER OR ABANDON
HOUSE @ $I 00 STATE ENCROACHMENT14
PERMIT NO. O
INDUSTRIAL F
WASTE APPROVAL W
a
CHARGES
OWNER'S I PERMIT $ 2 00 CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE � co REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEW R
SIGNED THIS AY OF 19G2! NEW HOUSE SEWER -
y- .
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADDRESS ' ✓J.G{ SEPTIC TANK,SEEP.PITS)
AND/OR DRAINFIELD
I 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
1HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT AM THE LEG OF THE ABOVE
DESCRIBED RESIDENT ROPERTYi BACKFILL SEPTIC TANKS ❑ ( AA ✓ .�
SEEP. PITS) ❑ CESSPOOLS ❑ '3v�
SIGNATURE
OF PERMITTEE
Or VALIDATI6CASH ROBERT A. WOOD
CIL M.0. SUPERVISING MECHANICAL ENGINEER
L&5 5 4 2110
ldV 29 0 6.00 �°