HomeMy Public PortalAbout5319TEMPLE CITY BLVD_Sewer X1284 APPLICATION FOR PERMIT 1
DIVISION OF BU=I G AND SAFsrx SEWER—SEWAGE DISPOSAL
DRparbme l Of CG�tT EngiRMr
County of Lw Ra4du BUILDING
WM J. FOX.COUNTY ENGINEER ADORES!
CA"ATT D.GRIFFIN.SUP T OF BUILDING LOCALITY
FOR APPLICANT TO FILL IN CRONEAREST By 1000of
SRDFCIa O 2 D• E1O OWNER
BLOCK TRACT �� 0 MAIL-
ADDRESJ:::��
NO OF BLDG!
512E OF LOT-11X-V," NOW ON LOT - CITY - TEL NO -
USE OF
BUILDING! DISTRICT N0
I GROUP 1 BK YAP
PO
CONTRACTOR A
ADDRESS Q CONNSCnON DATA
CI Y t. /TEL NO STATION ;79,_15'- DEPTH '
REOIST TION NO $ 3 0 COUNTY A MA UID fiFERENCE3OSIiL
.TWeOF CONNECTIO U LENGTH FROM
No DESCRIPTION OF WORK FEE T V CURB PL Y L TO P L
HOUSE SEWER CONNECTING TO
PUBLIC!EWER ! 5 80
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1 00 �J
CONADDITIONAL BLDG OR � 7y�
CONK K CTO CO IMP NO JOB NO HOUSE SEWER 100 _
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM 1 00 TRUNK PERMIT NO ROAD PERMIT NO
DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT
AMD/OR DISPOSAL SYSTEM 100 PERMIT NO
SEPTIC TANK SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 200 INDUSTRIAL
CESSPOOL.DRYWELL --- WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2 00 CHARGES
CONNECTION CHARGE FEE
ovnfwS pEUUT S 1 00
AUMOMATION TOTAL FEB REIMBURSEMENT FEE
1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING QWKLLINGpW KLLING APPROVALS DATE INS ECTOR S SIGNATURE
TO THE PUBLIC 5 _
SIGNED THI AY OF / M.0NEW HOUSB SEWER - '� 5 iloel
OWNER OR r CONNECT ADDITIONAL
OWNERS AGENT 0.
BUILDING OR WORK
SEEP
ADOBES AND/ORTANK DRAINFIELDPIT( )
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION CESSPOOL E3 ORYWELL❑
AND STATE THAT THE ABOVE 19 CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCE! AND STATE LAWS REGULATING ALTER, REPAIR,SEWER OR
PLUMBING AND SEWER! SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIPY THAT I AY PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISC ABANDON CT PLUG
SEWER
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIAL PROPERTY BACnILLseffr LEKSPoo.. 4
1g1,
SIGNATURE
OF PERMITTE
WIWAM J. FOX.COUNTY ENGIN[B7l VALIDATION
BY .tiwi 8 Bl 6M— HM'23 4 45 O r" $
I
e � DfieuTr � �'M�(„��y OfiPUT'T '
BY BY ryy
1 m DEPUTY '/ DEPUTY