HomeMy Public PortalAbout5729TEMPLE CITY BLVD_Sewer .E6C612-68 APPLICATION FOR PER IT
'6A 642Q
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER BUILDING
BUILDING AND SAFETY DIVISION ADDRESS
JOHN A. LAMBIE. COUNTY ENGINEER � >C�
COLEMAN W. JENKINS, SUPT. OF BUILDING LOCALITY
NEAREST
FOR APPLICANT TO FML IN CROSS 5T.
L GALOWNER / l"'t'..Z-.G2L-�✓
DESCRIPT__.ON__-LOT NO. P?-
MAIL
f / ADDRESS
BLOCK TRACT (°y - �
-
NO. OF SLOGS. CITY TEL. NO.
SIZE OF LOT - NOW ON LOT
M.AP PROCESSED BY
USE OF DISTRICT NO. GROUP BK PG
BUILDINGS e
CONTRACTOR ��" `: .ry'.�'
-- �^ CONNECTION DATA
ADDRESS ',��� y DEPTH r
_----7-�-- /y STATION ,_j--2
CITY --��� ♦♦♦ PIPER
�L'� —. LIC MANHOLE REFERENCE !_l.-T
STA- LOWER
LICENSE NO - _— L '- LENGTH FROM
_ TYPE OF CONNECTION -M.L.TO P.L. 5`NO. DESCRIPTION F WORK FEE__ Y CURB P.L.
HOUSE SEWER CONNECTING 70 �/r� - -----
V P.C.NO.
PUBLIC SEWER _- �_ 55.00 ` - —
—�.`Z /p� JOB NO. - _—
SEPTIC TANK.$EEPA GE PIT OR CO.IMP.NO. /� C> r
PIIS AND OR DRAINFIELD @ 510:00 __ --'""---
—} TRUNK PERMIT NO. ROAD PERMIT NO. G.
-HOUSE SEWER CONNECTING TO — I _—__- - --- O
PRIVATE DISPOSAL SYSTEM S3'00 - -- fi
CONNECT ADOIT70NAL BLDG.-OR — AFFIDAVIT WAIV[A [AsZKT17C
ORD.INSTR.NO. DATE
$3-00
WORK TO HOUSE SEWER J- _ ---- ---
OVERFLOW SEEPAGE PIT DRAINFIELD--- ---i-- -_--'�—------- ------_---
EXTN.,CE55POOL.DRYWEL.L.MANHOLE� c_')
:4VJy QRST.WIDENING LjJ.
ALTER REPAIR OR ABANDON HOUSE — I
E300 ---------
STATE ENCROACH.—ME-NT --- — _ nN
SE—EROR -
PFAM{T NO.
— —I¢ --I-- N*USTRIAL
WASTE APPROVAL___
CHARGES
OWNER°SPEHMII_ ---- st--2 Oo —-–TION C --- ------ _---
--} CONNECTION CHARGE FEE
AUTHORIZATION T 17 in el
-- - --- -- --- �—
REIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT' WITH THE HEREIN NAMED CON- --APPROVALS --�--- NATURE
TRACTOR T0..CONNECT THE ABOVE DESCRIBED EXISTING DWELLING ---- D {E 1 IN
CTOR'S 5 GNATU RE
TO THE PUBLIC SEWER, ----
i SIGNED THIS DAY 0r-
--y NEW HOUSE SEWER
OWNER OR yY, f " -✓ CONNECT ADDITION AL
$
OWNERAGENT - - _
_ , BUILDING OR WORK
�'r °� _--- ------- SEPTIC TANKI,SEEP,PIT(S)
1 HE
ACKNOWLEDGE D
EL
NFI
A
AND/OR OR
AT 1 HAVE READ THIS APPLICATION - __ ------
AND ATE THAT THE ACOVE IS CORRECT AND AGREE TO COMPLY ------
WITH ALL ::OUNTYORDINANCES AND STATE LAWS REGULATING CESSPOOL ❑ DRYWELL ❑ _,__-.---------
PLUMBING AND SEWERS.
1 HEREBY CERTIFY THAT I AM PROPERLY REGIST ERE[a AND/OaR� SEWAGE SEWER OR EM
LI CENSED,/A5J3 REQUIRED BY L05_,ANGLES COUNTY AND STATE ��I'" D?SCO NN ECT PLUG AND
CALIFCjil FVOR Tt�lOV AM etf GAL OWNER L AND INTEND T+b ABANDON HOUSE.SEWER
RES i THE p'bVE D CRI D RES E/N�J'A L.�f'ROPFjR .y � — ---
BAI KFILL SEPTIC TANKS ❑
SFt -.•�7 /`meq.-�l 444
A" SEEP.PIT(5) ❑ CE55POOL .�
OF P TTTEE_,—.-- - ---
VA IDATION JACK R. ALLEN
`SUPERVISING MECHANICAL ENGINEER
CK. M.O. CASH -
C c f