HomeMy Public PortalAbout5235TEMPLE CITY BLVD_Sewer (2) 55
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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