HomeMy Public PortalAbout4367TEMPLE CITY BLVD_Sewer :aasea It.159 APPLICATION FOR PERMIT 1
Dr=ON OF R=ING AND SAFETY SEWER—SEWAGE DISPOSAL
Depmhnont of County Englnae[
County of Las Angeles BUILDING -
JOHN A LAMBIE COUNTY ENGINEER ADDRESS
m CASSATTD GRIFFIN GUFTOFBUILDING LOCALITY
FOR APPLICANT TO FILL IN CROSS BY
LEGAL
DESCRIPTION LOT NO OWNER
BLOCK TRACT satMAIL -
� ADDRESS
NO OF BLDGS
91XE OF LOT NON ON LOT CITY TEL NO 2I
USE OF
BUILDINGS DISTRICT NO GROUP YAP
BK Pe
CONTRACTOR
ADDRESS CONNECTION DATA
CITY C TEL NO ON J DEPTH
MANHOLE REFERENCE
REGISTRATION NO 21 ❑ COUNTY OW
No DESCRIPTION OF WORK FEE
HOUSE!EWER CONNECTING TO TYPE OF CON NECiI ON LENGTH FRO
PUBLIC SEWER S 3 7R 0 Y CURS P L Y L TOP L
SEPTIC TANK,SEEPAGEPIT OR C L
PITS AMD/OR DRAINFIELD ® 3 00 u
OVERFLOW SEEPAGE PIT GRAINFIELD CO IMP N0, P C NONO
EKTN ,CESSPOOL,DRYWELL,MANHOLE ® $t 00 (7_ SOB
HOUSE SEWER CONNECTING TO p
PRIVATE DISPOSAL SYSTEM ® S 1 00 TRUNK PERMIT NO ROAD PERMIT NO 7
CONNECT ADDITIONAL BLDG OR STATE ENCROACHMENT
WORK TO HOUSE SEWER S 1 00 PERMIT NO
ALTER REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWr OR Dif YSTEY $1 00 WASTE APPROVAL
, CHARGES
CONNECTION CHARGE FE
Ovam'S I PEEDW s 00
0 O
AUTHORIZATION TOTAL FEE REIMBURSEMENT FE[
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- APPROVALS_ DATE JNSPECT2. ATURE
TRACTOR TO CONNECT THE ABOVE D ED EXISTING DWELLING
TO THE PUBLIC SEMEN EW HOUSESEWER
SIGNED THI CONNECT ADDITIONAL
OWNER OH BUILDING OR WORK
OWNERS AG[ SEPTIC TANK,SEEP,PIT(S)"
ADDREB AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT C I AYE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE IS RECT 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 YPROPE RE
GISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY OS ANGE OUNTY AND STATE OF
CALIFORNIA OR THAT I THELEG L HER OF THE ABOVE ABANDON HOUSE SEWER
DESCRIBED RESIDENTIA OP�I" BACKFILL SEPTIC TANKS❑
SIGNATURE P PIT SJ❑ CE POOLS
OF PERU]TTjp
JOHN A LAMBIE CGu ENGINEER �,IDATj0 ERT A WOOD CH oEc7GR
UC,06993 YM251 0 A 5.00 A