HomeMy Public PortalAbout4940TEMPLE CITY BLVD_Sewer akRG¢D 11"95 APPLICATION FOR PERMIT 1
DIVISION OF BUMDING AND SAFETY SEWER-SEWAGE DISPOSAL '
Dapartm*W of County Enylnew ,
County of Los AnpdeB ABUILDING
DDRESS y
JOHN A LAMBIE COUNTY ENGINEER
m CA88ATT D GRIFFIN SUP T Or BUILDING LOCALITY
FOR APPLICANT TO FILL IN CROSS 3ST
LEGAL 01/NEB
DESCRIPTION LOT NO / ♦ w
BLOCK TRACT I K N C MAIL
ADDRE99
NO OF BLDGS
SIZE OF LOT 16P NOW ON LOTqO �AT'E�
CITY TEL NO
UBE OF
BUILDINGS DISTRICT NO GROUP YAP '
PlIr PG
CONTRACTOR
ADDRESS 6 / CONNEGTIOfr DAiA
CITY TEL NO STATION DEPTH
MANHOLE REFERENCE UPPER
LOWER
REGISTRATION NO DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TOTYPE OF CONNECTION LENGTH FROM
PUBLIC SEWER @ $3Y CURB P L Y L TO P L
EPTIC TANK SEEPAGE PIT OR
PITS AND/OR GRAINFIELD ® S 3OVERFLOW SEEPAGE PIT DRAINFIELD P C N
EKTN CESSPOOL DRYWELL MANHOLE ® SZCO IMP NOHOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM ® SITRUNK PERMIT NO RO PERMIT NO -
CONN ECT ADDITIONAL BLDG OR STATE ENCROACHMENT
WORK TO HOUSE SEWER @ $1 00 L PERMIT NO
ALTER REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM ® S 100 WASTE APPROVAL -
CHARGES
CONNECTION CHARGE FEE_ '
OWNER'S PERMTI s 1 00
AUTHORTLATION TOTAL FEE REIYBURSEYENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON APPROVALS DATE INSPECTOR SSIGNATURE
TRACTOR TO CONNECT THE ABOVE OESCRIBED EXISTING DWELLING
TO THE PUBLIC EWER NEW HOUSE SEWER
SIGNED THIS- /AY OF 19� CONNECT ADDITIONAL ZZ
OWNER OR C . BUILDING OR WORK
OWNERS AGENT_ _ �fi�1� SEPTICTANK BEEP, PITS)
ADDRESS I AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE 13 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 AY PROPERLY REGISTERED AMD/OR 013CON XECT D
PLUG AN
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HO PLUGD
CALIFORNIA OR THAT I AN THE LEGAL OWNER F T E ABOVE
DESCRIBED RESIDENTIAL PROPERTY ^ A BACKFILL SEPTIC TANKS
SIGNATURE ` 3EEP PIT(SI
❑ CESSPOOLS❑
OF PERMITTEE
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—A
JOHN A LAMBIE COUNTY ENGINEER VALIDATION ROBERT A WOOD CHIEF PLBO INSPECTOR
LK ¢ 0 GSH
L&8465D; MAY23 4 200 ID