HomeMy Public PortalAbout9414 EMPEROR AVE_Sewer__ &E-6D89 I f 98
H APPLICATION FOR PERMIT
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DIVISION OF BUILDING AND SAFETY SEW E R-SEWAGE DISPOSAL
Department of County Engineer
County of Los Angeles BUILDING
JOHN A LAMBIE, COUNTY ENGINEER ADDRESS
® CASSATT D GRIFFIN, SUP T OF BUILDING
LOCALITY
FORNEAREAQP TO FILL— IN 30
CROLEGL SsT O
.
DESCRIPTION LOT NO OWNER !NO
� MAIL
BLOCK TRACT � B�'' ADDRESS
•' NO OF BLDGS CITY TEL
SIZE OF LOT 10 �® NOW ON LOT
USE OF
BUILDINGS DISTRICT NO GROUP MAP
J�
BK PG
CONTRACTOR ^
ADDRESS CONNECTION DATA
� �p � _ f .�+
r STATION `. Q Lt DEPTH
CITY �l l ti- ✓, yEL NO �
MANHOLE REFERENCE ._
�+ ATE _t%6 LOWER
REGISTRATION NO - El
No DESCR TION OF ORK FEE
HOUSE SEWER CONNECTING TO TYPE OF ECTION LENGTH FROM
PUBLIC SEWER @ $3 50 Y P L M L TO P L
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD Q $3 00
OVERFLOW SEEPAGE PIT DRAINFIELD P C NO
EXTN CESSPOOL,DRYWELL,MANHOLE c@ $2 00 CO IMP NO ,3aY JOB NO
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM Q $1 00 TRUNK PERMIT NO ROAD PERMIT NO
CONNECT ADDITIONAL BLDG OR STATE ENCROACHMENT
WORK TO HOUSE SEWER Q $1 00 PERMIT NO
ALTER REPAIR OR ABANDON HOUSE INDUSTRIAL -
SEWER OR DISPOSAL SYSTEM Q $100 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT $ 1 00
AUTHORIZATION I TOTAL FEE `?' REIMBURSEMENT FEE 1L16*/10�fc� eaGD��PL
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- APPROVALS DATE INSPECTOR S'SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER NEW HOUSE SEWER
SIGNED THIS DAY OF 19 CONNECT ADDITIONAL <
OWNER ORa BUILDING OR WORK _
OWNERS AGENT��� SEPTIC TANK,SEEP,PIT(S)
ADDRESS AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
AND STATE TH,T 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/ORS DISCONNECT PLUG AND
LICENSED AS REQUIRED BY,FLOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT 1,pM�THE LEGAL OWNER,-OF THE ABOVE
DESCRIBED RESIDENTIAL' ROPERTY i r ' BACKFILL SEPTIC TANKS❑
SIGNATURE <',�'o^ ��,— SEEP PIT(S) [:1 CESSPOOLS❑
OF PERMITTEE XXX F' 7
JOHN A LAMB , COUNTY ENG I ER VALIDATION ROBERT A WOOD, CHIEF PLBG INSPECTOR
CASH
rQ a 2 4 7Lcf; AUL 16 4 4.5 0 In