HomeMy Public PortalAbout5340TEMPLE CITY BLVD_Sewer "°" 4"
• eeAPPLICATION FOR PERMIT 1
eKDIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
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WIA J FOX. COUNTY ENGINEER ADORES!
CMBATT D GRIFFIN BDP T OF YUILDINe LOCALITY C Com/
FOR APPLICANT TO FELL IN NEARESTr �L / ��
CROSS B
LEGAL / C A-
DESCRIPTION LOT NO OWNER
BLOCK TRACT Y DRESS % 1-
DG
SIZE OF LOT NOYOONBLOTS CITTY t- [y/( �/ TEL NO �� .7124?
USE OF /
BUILDINGS YYG4
1_//J[` DISTRICT NO GROUP YAP
CONTRACTOR 4
I BK PG
/92, 1
ADDRESS COMECTION DATA
CITY TEL NO STATION Q O/ d DEPTH /
❑ STATEA!,01
EFERENCE
REGISTRATION NO FI COUNTY PPER iGWNP
TYPE OF CONNECTI P L LENGTH FROM
NO DESCRIPTION OF WORK FEE ••t
HOUSE SEWER CONNECTING TO
PUBLIC SEWER ® S S SO ^���
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1 00
CONNECT ADDITIONAL BLDG OR CO IMP NO 2 6 JOB NO
WORK TO HOUSE SEWER 100
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM 1 00 RUNX PERMIT NO ROAD PERMIT NO
DISCONNECT AND ABANDON SEWER STATE CHYENT
AND/OR DISPOSAL SYSTEM 1 00 PERMIT NO
SEPTIC TANK SEEPAGE PIT OR
_ PITS AND/OR DRAINFIELD "too INDUSTRIAL
CESSPOOL-DRYW ELL -- WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2 00 CHARGES
CONNECTION RGE FEE
OwNmm'S PERINUT $ 1 00
AUTIIORMATION TOTAL PEE G�. S-� REIISITISEMENT FEE
I HAVE DATETRACTORTHIS TO CONNECT i EACTED ABOVEYITH DESCR SED EXISTINGTHE HEREINAMED DWELLIN APPROVALS DATE INSYECTOR S SIGNATURE
TO THE PUBLIC SEWER -
� � �j ��' 7X NEW HOUSE SEWER
SIGNED THIS OF I9LJ
OWNER OR CONNECT ADDITIONAL
OWN101S A9QNT RUILOING OR WORK
ADDRESS SEPTIC TANK, SEEP PIT($)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER, REPAIR,SEWER OR
PLUMBING AND SEWERS pp SEWAGE DISPOSAL SYSTEM
LICENSED!ASCERTIFYREQU REDN BY LOSY P ELES COUNTY!AND STATEED /OR
OF
! DISCONNECT PLUG AND
CALIFORNIA OR TNT 1 AN 7N LEGAL O HER OF THE ABOVE ABANDON HOUSE SEWER
DESCRIBED RES IAL PI OPE Y SACXFILL SEPT C TANKS❑
SI ONATU
�'�JY/ice SEEP P{T S CESSPOOLS
OF PE YTE
WILLIAM J FOX,COUNTY ENGINKIM VALIDATION P
by
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