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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