HomeMy Public PortalAbout9154 EMPEROR AVE_Sewer__ . 76A 642D
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A P SOI Q AT I O N 1FO R PERMIT 1
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DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Department of County E'ginee^ a "
County. of Los Aageles BUILDIN� {, _
ADDRESS !a ,� 1„
WM. J. FOX, COUNTY ENGINEER
CASSATT D. GRIFFIN,SUPT OF BUILDING / r,
LOCALITY .,7Ja•. ` i:�'t'.. -
FOR APPLICANT TO FILL IN_ NEAREST
CROSS ST. 51_
LEGAL _ - <�"` /j 0 1 -
DESCR .3. N SOT `__' l/ OWNER � , le
BLOCK TRACT i MAIL
_ � Y ' ltd✓ 4•'� Y_
NO.OF BLDGS. ADDRESS
1`�,
SIZE OF LOT NOW ON LOT CI Y -t/ TEL'./Lo-
USE OF K,
BUILDINGS _ < 'R'y/t,! ,✓ G./
- DISTRICT N0. I GROUP I MAP
SK PG
CONTRACTOR
ADDRESS . ®�C_!G�"`"� CONNECTION DATA
CI Y �lI(-yf TEL. STATION DEPTH
Er '--STATE 11� MANHOLE REFERENCE
REGISTRATION NO. ❑ COUNTY `a'�', ,y �L� d#E:Pyzl' LOWER
v TYPE OFCONNECTION. LENGTH FROM _
No. DESCRIPTION OF WORK FEE Y. CURB rL:;-�.� M.L.TO P.L.
IL
SEWER CONNECTING TO
--- PUBLIC SEWER Qa $ 3.50
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG. OR CO. IMP. NO. /��� n JOB. NO.
WORK TO HOUSE SEWER 1.00 _ y� l'-� 1>✓
ALTER OR REPAIR. EXISTING
SEWER OR DISPOSAL SYSTEM 1.00 TRUNK PERMIT NO. ROAD PERMIT N0,
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
SPECIAL CONDITIONS ONLY 2.00 CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT $ t 00
AUTHORIZATION I TOTAL FEE REIMBURSEMENT FEE
1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED CON- O
TRACTOR TO CONNECT THE ABOVE DESCRIB EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC S ER
SIGNED THIS �' Y OF t9 NEW HOUSE SEWER -� � � �V C�&
OWNER OR CONNECT ADDITIONAL
OWNERS .O GEN BUILDING OR WORK
SEPTIC TANK, SEEP, PIT(S)
ADDRES /'ter' /$ »- .AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAA�T HAVE READ THIS APPLICATION CESSPOOL[IDRYWELL[IAND STATE THAT THE ABOVE I$ CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANC S 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 - ABANDON HOUSE SEWER
CALIFORNIA OR THAT. I AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS❑
�•.,y�_ SEEP:PITS) ❑ CESSPOOLS
SIGNATURE "~ ,.
OF PERMITTEE
WILLIAM J. FOX, COUNTY ENGINEER VALIDATION
In
67
'Co 58Y1Sn JM 5 4 4.50
DEPUTY DEPUTY
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;® DEPUTY �vc ''°'6� / -� DEPUTY