HomeMy Public PortalAbout4940TEMPLE CITY BLVD_Sewer (2) �e�aeOa 11 YY APPLICATION FOR PERMIT ,
DIVISION OF BUHMING AND SAFETY SEWER—SEWAGE DISPOSAL
Department of County Engineer
County of Los Angeles BUILDING
JOHN A LAMBIE COUNTY ENGINEER ADDRESS '
m CASSATT D GRIFFIN SUP T GE BUILDING LOCALITY do 023P
FOR APPLICANT TO FILL. IN CCROSS s
LEGAL
DE9CRIPTIOX LOT NO OWNER
BLOCK TRACT MAIL
ADDLES$
O 6F BLDGS CITY TEL NO
SIZE OF LOT NOW ON LOT
USE OF DISTRICT NO GROUP YAP
Bm Lmnas
1 PG
CONTRACTOR
ADDRESS 41a�6E CONNECTION DATA
STATION DEPTH
CITY TEL NO MANHOLE REFERENC .. UPPER
ATE LOWER
REGISTRATION NO COUNTY
NO DESCRIPTION 4 WORK FEE
HOUSE SEWER CONNECTING TO PE OF NNECTION LEN6TH FR6m
PUBLIC SEWER @S Y CURB P L M L TOP L
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD ® $9 00
OVERFLOW SEEPAGE PIT DRAINFIELD P C -
EKTN CESSPOOL,DRYWELL MANHOLE ® S 200 CO IMP NO 1 10
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM a $1 00 TRUNK PERMIT NO ><IBOAD PERMIT NO
CON N ECT ADDITIONAL BLDG OR STATE ENCROACHYE
WORK TO HOUSE SEWER ® $100 PERMIT NO
ALTER,REPAIR OR ABANDON HOUSE ter., INDUSTRIA
SEWER OR DISPOSAL SYSTEM ® S 1 00 WASTE APPROVAL -
CHARGES
N
CONNECTION CHARGE FEE
OWNER'S PEHM T s 00
AUTHORIZATION TOTAL FEELZJLREIMBURSEMENTPRO FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- APPROVALS DATE INSPECTOR S9IGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEW;R NEW HOUSE SEWER
SIGNED THI DAY O 19 CONNECT ADDITIONAL
OWNER M BUILDING OR WORK
OIS.ae ws" V., SEPTIC TANK SEEP PIT(S)
ADDREg AND/OR DRAINFIELD ,
1 HEREBY ACKNOWLEDGE TPrAT 1 HV READ THIS APPLICATION CESSPOOL❑ ORYW ELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWEROR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM/
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE ABANDON HOUSE SEWER
DESCRIBED RESIDENTIAL PROPERBACKFILL SEPTIC TANKS
SIGNATURE l SEEP PITS) 0 CESSPOOLS 0
OF PERYITTE ica ,
JOHN A LAMBIE COUNTY ENGINEER VALIDATION ROBERT A WOOD, CHIEF PLBG INSPECTOR
( - Llra2 2`7-9 M FEB ( 1 O A 3 it
- 1