HomeMy Public PortalAbout5746-5748TEMPLE CITY BLVD_Sewer (2) DEPAItrMENT OF COUNTY ENGINEER SEWER-SEWAGE DISPOSAL
.DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
10 COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER BUILDING,_; q _ 4� �y# i
ADDRESS,5 j^C�.w t Y CIL, 33i ud
3
FOR APPLICANT TO FILL IN LOCALITY—I—t C
BUILDING NEAREST
ADDRESS GROSS ST.
LOCALITYt' ' DISTRICT NO. SERIAL NO. PERMIT NO.
NEARESTS
C
CROSS ST.
f" r
ECEIVED BY Ready for Inspection DATE ISSUED
OWNER a ✓ ' "fi' +,I
MAIL
ADDRESS USE ZOAE OCCUPANCY MAP
SK PG
CITY TEL.NO.
CONTRACTOR
CO.IMP.NO. - A
ADDRESS ,
- JOB NO.
CITY TEL.NO. TRUNK PERMIT N0.
y. y [�
REGISTRATION NO. Li STATECOUNTY ROAD PERMIT NO.
LEGAL __
DESCRIPTION LOT NO. STATE ENCROACHMENT
PERMIT NO.
BLOCK TRACT INDUSTRIAL
WASTE APPROVAL
SIZE OF LOT NO.OF BLOGS.
NOW ON LOT CHARGES
USE OF
-BUILDINGS CONNECTION CitARGE FEE
NO. DESCRIPTION OF WORK FEE q
—i HOUSE SEWER CONNECTING TO REIMBURSEMENT FEE
r PUBLIC SEWER @ $ 3.50 RECEIPT NO. --bA/ BY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00 �t
CONNECT ADDITIONAL BLDG.OR EXCEPTION RECORDED `-y
WORK TO HOUSE SEWER 1.00
ALTER 8R REPAIR EXISTING 1.00 NO- I DATE I BY
SEWER OR DISPOSAL SYSTEM
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1.00 CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 2.00 �- d f
CESSPOOL—DRYWELL STATION ) � f DEPTH 'J
SPECIAL CONDITIONS ONLY 2.00
UP ER EFERENCE
TYPE OF CONNECTION— LENGTH FROM o
OWNERS PERMIT ; I 00 P.L::- M.L.TO P.L. '
AUTHORIZATION TOTAL FEE
1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING
DWELLING TO THE PUBLIC SEWER APPROVALS INSPECTOR'S SIGNATURE DATE
SIGNED THIS.........:...--.....DAY. OF-------_....- .................19...... NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT........ ............ BUILDING OR WORK
ADDRESS.-..--.. '-._...,...... SEPTIC TANK,SEEP.PIT(S)
......... _-- -...._..... ...., AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLI- CESSPOOL[] DRYWELL
CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER,REPAIR,SEWER OR
REGULATING PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND
DISCONNECT PLUG
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOPLUGAND
AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN-
ER OF THE ABOVE DESGRIBED RESIDENTIAL PR,CPERTY. BACKFILL SEPTIC TANKS
SIGNATURE SEEP.PIT(S)[] CESSPOOLS(�
OF PERMITTEE..... ... r-.�.. :.s. - ................... -
i
` vA642D 663 1/53