HomeMy Public PortalAbout5420 ACACIA ST_Sewer_4/20/1979_Connection charge TEMPLE CITE ,
r.pios D ' ,� ICATION F0f(,'PERM'IT ' 1
CE808 8 88"
COUNTY OF LOs GIMES •xS.EWER SEWAGE 'DISPOSAL ,
D ARTNIENT OF COUNTY ENGINEER
U;LDING AND SAFETY DMSION - BUILDING, " C
OHN A, LAMBIE, Countr Engaees
5i ST D. GRIFFIIi, Sup t of$u�ldmg LOCALITY r
NEAREST `
OR APPLICANT TO FILL IN caoss sra
DESCRIPTION LOT NO OWNER.
MAIL
BLOCK TRACT - ADDRESS-' tZ "
ti- i 0 OF BLD S
,SIZE OF LOTSIC '3 I NOW ON LOT CI NO .� F"-A -
U s-Elo F
BUILDINGS DISTRICT NO GROUP G`� KOP PROLE D BY
rCONTR'ACTOR" ♦d/'O � / I
ADDRESS CONNECTION DATA
CITY `a TEL NO STATION DEPTH _
' B STATE MANHOLE REFERENCE w UPPER
REGISTRATION NO COUNTY -LOWER-
No DESCRIPTION OF WORK FEE
PUBLIC EWE CONNECTING TO
SEWER @ 3300
SEPTIC TANK SEEPAGE PIT OR TYPE OF CONNECTION LENGTH FROM
=PITS AND/OR DRAINFIELD @ $300 Y CURB P L M L TO P L
+ `tEXTNFLC SSPOOLGDRYWELLpINFIELD @ $200
•PRIVATE DISPOSAL SSE SEWER YSTEM TO @ sl o0. CO IMP NO 73 JOB NO
-CONNECT HOU9EISEWER BLDG OR @ Sf 00 TRUNK PERMIT NO ROAD PERMIT NO
SEWERREPAIR
R DISPOSAL SYSTEM HOUSE @ $1 00 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL `
' CHARGES
CiWNER+S PEnUT g 2 00 CONNECTION CHARGE FEE
•
22
AUTHORIZATION TOTAL FEE 22
1'HAVE AT,THIS DATE A CO =TRACT WITH THE HEREIN NAMED•CON-• w "
TRACTOROTO CONNECT,TH ABOVE DESCRIBED EXISTING DWELLING 'APPROVALS DATE INSPECTOR S SIGNATURE
TO THE.PUBLIC SEWE
SIGNED'THI 'DAY OF 19 NEW HOUSE SEWER
OWNERmOR -'' • -
' CONNECT%ADDITIONAL
OWNERSiAGENTUIL'DING OR WORK
_ n
$i ..
ADORES ' ' - • EP,TIC TANK SEEP PIT(S)
kND/OR DRAI!FIELD
1'+HEREBY,ACKNOWLEDGE THAT 1 AVE READ TH18'9PPLICATION
AND STATE THAT ,THE ABOVE IS CORRECT AND AGREE TO COMPLY !CESSPOOL ❑ DRYWELL ❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS pLTER;REPAIR SEWER OR
i•HEREBYa CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR` SEWAGE DISPOSAL SYSTEM
LICENSED-'AS•REOUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT I AM LEGAL OWNER OF THE ABOVE ABANDON HOUSE SEWER
DESCRIBED RESIDENTIAL PROP ► BACKF,ILL SEPTIC TANKS ❑
SIGNATURE - - SEEP PIT(S ❑ CESSPOOLS
OF PERMITTE
R� YAJUbATION ROBERT A WOOD
CIL M 0 cum SUPERVISING MECHANICAL ENGINEER
B30�1433Q! APR,208 .1 0 668.97& - -