HomeMy Public PortalAbout9150 EMPEROR AVE_Sewer__ TION ,FO-R PERMIT
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DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL
Department of County Engineer
County of Los Angeles BUILDINADDRESS `�" t� Vey �'�A��.�
WM.J. FOX, COUNTY ENGINEER
CASSATT D. GRIFFIN, SUPT OF BUILDING LOCALITY � � �p "T,
FOR APPLICANT TO FILL IN NEAREST �u
.,� CROSS ST. �
LEGAL
DESCRIPTION LOT NO. OWNER
BLOCK TRACT 94MAIL '
y-� NO. OF BLDGS! ADDRESS
_ SIZE OF LO&& X o NOVON LOT CITY TEL. NO.
USE OF
BUILDINGS DISTRICT NO. I GROUP MAP =
CONTRACTOR nag 1F SEUER MIST BK PG
ADDRESS CONNECTION Pmt �tan�r CONNEC—TION DATA
,��
CITY y�y � t y TEL. N0�9p 1-5048 STATION 3- DEPTH ?
(STATE)
E�fY4 S t�_�JIJ ❑ STATE MANHOLE REFERENCE
REGISTRATION NO. 148659 l S 1 ATE) ❑ COUNTY It.� 4.3 6 �, UPPER
TYPE OF CONNECTION LENGTH FROM
NO. DESCRIPTION OF WORK FEE �`�- 11 �- P.L. M.L.TO P.L. CQ.
HOUSE SEWER CONNECTING TO �,�y
_ PUBLIC SEWER @ $ 3.50y`l
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
-� CONNECT ADDITIONAL BLDG. OR
WORK TO HOUSE SEWER 1.00 CO. IMP. N0. JOB. N0.
r7
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 INDUSTRIAL
CESSPOOL- DRYWELL WASTE APPROVAL
S PECIAL CONDITIONS ONLY 2.00 CHARGES
CONNECTION CHARGE FEE
OWNERS PERMIT $ _ 00
AUTHORIZATION TOTAL FEE 14n,Irl REIMBURSEMENT FEE
TRACTORHAVE TTO CONNE THIS DATE ONTRTHEAABOVE DESCRIBED EXIISTINGCTED WITH THE HEREIN A DWELLING APPROVALS DATE INSPECTORSSIGNATURE
TO THE PUBLIC SEWER �y
NEW HOUSE SEWER
SIGNED THI DAY OF 1Z-
OWNER ORjif 12PCONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
SEPTIC TANK, SEEP, PIT(S)
ADDRESS AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
AND 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 REQUIRED BY LOS ANGELES COUNTY AND STATE OF
CALIFORNIA OR THAT I AM T,HE L •GAL OWNER OF THE ABOVE ABANDON HOUSE SEWER
DESCRIBED RESIDENTIAL PROP•RTY. BACKFILL SEPTIC TANKS❑
SEEP. PIT(S) ❑ CESSPOOLS
SIGNATURE
OF PERMITTE
Egmumxua
WILLIAM J. FOX,COUNTY ENGINEER VALIDATION
BYIL
rr .11, 07 ..620 ?-1 SEP 6 4 4 .5 0
DEPUTY 7 - 0 3 U, Std' 6 4 2.0 r � DEPUTY �.
BY BY
0 DEPUTY DEPUTY