HomeMy Public PortalAbout9413 EMPEROR AVE_Sewer__ -61
76A6423-61
. APPLICATION FOR PERMIT
76A 642
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DMSION BUILDING
JOHN A, LAMBIE. CouatY Engc�inneer ADDRESS
WILLIAM A JENSEN, Supt
of Building LOCALITY A
NEAREST �l
FOR APPLICANT TO FILL IN CROSS ST (j
LEGAL
DESCRIPTION LOT NO OWNER U
BLOCK TRACT MAILU
A DRESS/6 1��
NO OF BUbGS /
SIZE OF LOT NOW ON LOT CITY ImakTEL NO
USE OF
f BUILDINGS �. �I/(.I/ DISTRICT NO GROUP BK MAP P8 Pgr.RSED BY
CONTRACTOR 1/ ��
ADDRESS 3J Q, CbNNECTION DATA
CITY Pa tN1,�, TEL NO STATION DEPTH
STATE REGISTRATION NO COUNTY MANHOLE REFERENCE UPPER
No DESCRIPTION OF _ FEE LOWER
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $300 OF CONNECTION LENGT ROM
SEPTIC TANK SEEPAGE PIT OR Y URB P L M LoTO P L
PITS AND/OR DRAINFIELD @ $S 00
OVERFLOW SEEPAGE PIT DRAINFIELD C'
EXTN CESSPOOL DRYWELL @ $2 00 �-
HOUSE SEWER CONNECTING TO P C NO. O
PRIVATE DISPOSAL SYSTEM @ 51 00 CO IMP NO JOB NO U
CONNECT ADDITIONAL BLDG OR TRUNK PERMIT NO D PERMIT NO a'
WORK TO H Si 00
TER REPS OSAL SYSTE HOUSE @ $l 00 1 STATE ENCROAC ENT O
!/ PERMIT NO `V
INDUSTRI a
WASTE ROVAL N
CHARGES ?
OWNER'S PERMIT 2 OO CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
1 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 SEWER
SIGNED THIS DAY OF 19— NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADDRESS SEPTIC TANK SEEP PIT(S)
AND/OR DRAINFIELD
LDESCRIBED
EBY ACKNOWLEDGE THAT t HAVE READ THIS APPLICATION
TE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL
LL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWER OR
G AND SEWERS SEWAGE DISPOSAL SYSTE
EBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
D AS REQUIRED BY OS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER J T
NIA OR THAT 1 THE GYLWN��DF THE ABOVE
ED RESIDENTI OPERTY. BACKFILL SEPTIC TANKS ❑RESEEP PIT(S ❑ CESSPOOLSMITTE U
VAIMATIOROBERT A WOOD
CR M o (CASH/ SUPERVISING MECHANICAL ENGINEER
L�,,C_)? 4 0N 2 6 l 0 0 3 .00