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HomeMy Public PortalAbout5235TEMPLE CITY BLVD_Sewer (2) 55 ••Mago IMSION OF BUWINGG MM SSAFION -SEWER RMIT DEpySEW GE DISPOSAL 1 D"wmsat of Comte EngiaMr ComM I Los ANTY E ADDRESS }23] N l C= a JOHN A LAMBIE COUNTY ENGINEER ADDRESS D CASSATTD GRIFFIN SUP T OF BUILDING LOCALITY E REST FOR APPLICANT TO FILL. IN MR059 ST LEGAL DESCRIPTION LOT NO OWNER P 7aL MAIL BLOCK TRACT ADDRESS ,NO OF BLDG9 CITY TEL NO , SIZE OF LOT NOW ON LOT DUILDINGS USE OF / BUIDISTRICT NO GROUP IMP BK PO CONTRACTOR 0, rZ— � ADDRESS �y. �/ CONNECTION DATA CITY TEL NO (A/ 6'�r 0/ STATION DEPTH /Y76/26 �/ MANHOLE REFERENCE Q STATE • LOW REGISTRATION NO ❑ COUNTY XO DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM HOUSE SEWER CONNECTING TO PUBLIC SEWER @CURB P L ML TOP L SEPTIC TANK,SEEPAGE PIT OR PITS AMD/OR DRAINFIELD a $3 00 OVERFLOW SEEPAGE PIT ORAI NFIELD CO IMP NO dpc No j4c7!5444 EKTN CESSPOOL DRYWELL MANHOLE S E 00 HOUSE SEWER CONNECTING TO /f PRIVATE DISPOSAL SYSTEM ® s 1 00 TRUNK PERMIT NO ROAD PERMIT NO "J CON M ECT ADDITIONAL BLDG OR STATE ENCROACHMENT /,• r• WORK TO HOUSE SEWER a s 100 PERMIT NO ALTER REPAIR OR ABANDON HOUSE INDUSTRIAL SEWER OR DISPOSAL SYSTEM s 100 WASTE APPROVAL CHARGE! CONNECTION CHARGE FEE OWNERS PEDW s 00 AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE 1 HAVE AT THIS GATE A CONTRACT WITH THE HEREIN NAMED N - APPROVALS DATE INSPECTO ATURE TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SE++WSfER NEW HOUSE SEWER SIGNED THIS OF VAN 19—f CONNECT ADDITIONAL OWNER OR' BUILDING OR WORK OWNERS AGENT SEPTICTANK SEEP,PIT(S) ADDRESS_ �'Yp AND/OR DRAINFIELD 1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THI APPLICATION CESSPOOL❑ ORYWELL❑ AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCE! AND STATE LAWS REGULATING ALTER,REPAIR SEWER OR PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM 1 HEREBY CERTIFY THAT 1 AN PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND LICENSED AS REOUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY BACKFILL SEPTIC TANKS J SIGNATURE SEEP PIT(S) ill CESSPOOLS C / / OF PERYITTE IN JOHN A LAMBIE COUNTY ENGINEER VAMATIO� ROBERT A WOOD,CHIEF PLBG INSPECTOR 3S/ _ ?` ol 7 JAN $ 1 0 A 5.0 0 S