HomeMy Public PortalAbout5925 ALESSANDRO AVE_Sewer__ TEMPLE CITY
76A642-62D APPLICATION FOR PERMIT
76A642
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS 5925 Ns Alessandro Awe•
COLEMAN W. JENKINS, SUPT. OF BUILDING Temple Cit
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST. Las Tunas
LEGAL ✓J j�j
DESCRIPTION LOT NO./j •��" :� �� OWNER )I)J® F. Toms
7 MAIL 7��
BLOCK TRACT ADDRESS 25 N. Alessandro Awe.
NO. OF BLDGS.$r
SIZE OF LOT NOW ON LOT • CITY T.C. TEL. NO.
USE OF
BUILDINGS BK DISTRICT NO. GROUP MAP PG PROCESSED BY
L'�'
CONTRACTORSquare Deal Sewer Service , 1--7-- /4'6�
ADDRESS 2933 Maxs on Rd. n CONNECTION DATA/
CITYEJ Monte TEL. NO. 4.44-202C STATION G r DEPTH /
J •yl F� UPPER
STATE LIC MANHOLE REFERENCE
LICENSE NO:. 128870 c-s. 2 S41
OWEF2�'.
NO. .DESCRIPTION OF WORK FEE TYPE O .Nt�LE-CTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L. >'
PUBLIC SEWER @ $5.00 OO 4.
SEPTIC TANK,SEEPAGE PIT OR P.C.NO. O
JOB NO.NO
IMP. .
PITS AND/OR DRAINFIELD @ $10.00 CO. V
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. Ix
CONNECT
DISPOSAL SYSTEM @ $3.00 O
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE
WORK TO HOUSE SEWER @ $3.00 V
OVERFLOW SEEPAGE PIT.DRAINFIELD W
EXTN.,CESSPOOL.DRYWELL.MAN HOLE @ $5.00 d
ALTER.REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING Ny
SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHMENT o
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT $ 21 00 CHARGES
AUTHORIZATION I TOTAL FEE 00 CONNECTION CHARGE FEE
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS
TO THE PUBLIC SEWER. D TE INS' CTOR'S IG ATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT_ CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION SEPTIC TANK,SEEP,PIT(S)
AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER AND INTEND TO DISCONNECT PLG AND
RESIDE IN, THE ABOVE DESCRIBED RESIDENTI PRO ERTY. ABANDON HOUSEUSEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑ 7/,
OF PER MTTTEE SEEP.PIT'S) ❑ CESSPOOLS13
VALIDATION JACK R. ALLEN
SUPERVISING MECHANICAL ENGINEER
CK. M.O. CASH