HomeMy Public PortalAbout9404 EMPEROR AVE_Sewer__ S&E 6691198 _ APPLICATION FOR PERMIT 1
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DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Deportment of County Engineer
County of Los Angeles BUILDING �+
JOHN A LAMBIE COUNTY ENGINEER ADDRESS '��� L/—•/ylf✓G/�p�
® CASSATT O GRIFFIN SUP T OF BUILDING LOCALITYEAREST
FOR APPLICANT TO FILL IN {' CROSS STLEGAL
C�a•� �����
DESCRIPTION LOT NO p?'mr,�✓j.,�ff 'rC /� OWNER `
`, MAIL
BLOCK TRACT ..o' j`7ADDRESS
NO OF BLDGS / CITY TEL NO
SIZE OF LOT NOW ON LOT
USE OF DISTRICT NO GROUP MAP
BUILDINGS
BK PG
1 0�
CONTRACTOR 10-ave
ADDRESS EJ,yt���. �� ,. CONNECTION DATA
CITY /a TEL NO ¢ vel
STATION �'�y DEPTH
�-�/' MANHOLE REFERENCE `�'p U PER ,
Of-STATE ✓
REGISTRATION NO �� a ❑ COUNTY
NO DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO TYPE OF CONNECTION LENGTH FROM
Y CURB P L M L TO P L
PUBLIC SEWER @
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ $3 00
OVERFLOW SEEPAGE PIT DRAINFIELD P C NO
EXTN ,CESSPOOL,DRYWELL,MANHOLE @ $2 00 (0 IMP NO f�r� JOB NO
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM @ $1 00 TRUNK PERMIT NO ROAD PERMIT NO
CONNECT ADDITIONAL BLDG OR STATE ENCROACHMENT
WORK TO HOUSE SEWER @ $1 00 _PERMIT NO
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM Q $1 00 WASTE APPROVAL t
CHARGES
CONNECTION CHARGE FEE _
OWNER'S PERMIT $ 00
AUTHORIZATION TOTAL FEE � �� " REIMBURSEMENT FEE �,eJ
APPROVALS DATE INSPECTOR SSIGNATURE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING r�
TO THE PUBLIC SEWER NEW HOUSE SEWER
SIGNED THIS DAY OF 19 CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK _
OWNERS AGENT 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
1 HEREBY 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 I M THE L GAL OWNER OF THE ABOVE
DESCRIBED RESIDENT[ PR PERTY BACKFILL SEPTIC TANKS❑
SIGNATURE SEEP PIT(S) ❑ CESSPOOLS
OF PERMITTEE
JOHN A LAMBIE, COUNTY ENGINEER ALIDATION ROBERT A WOOD, CHIEF PLBG INSPECTOR
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