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HomeMy Public PortalAbout5811-5811 1/2-5813TEMPLE CITY BLVD_Sewer APPLICATION FOR PERMIT S$£SSS 3-55 1 DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE D I SPOSA L Department of County Engineer County of Los Angeles BUILDING g 5 WM.J. FOX,COUNTY ENGINEER ADDRESS s a CAPLOCALITY SSATT D.GRIFFIN, SUPT OF BUILDING p NEAREST FOIA, APPLICANT TO FILL IN __CROSS sT. J LEGAL J_DESCRIPTION LOT 140. i' OWNER, BLOCK BLOCK TRACT d< I MAIL " C_ _ADDRESS � )' 9'`.. 4-0 7 NO. OF BLDGS. r SIZE OF LOT ��)J p, MOiJ ON LOT CITY �y,. fr" TEL,NO. l` USE OF BULLDiNb'S ___ _ DISTRICT N0, ( GROUP I MAP oG i BK PS CONTRACTOR ADDRESS . CONNECTION DATA CITY.- --'-----T, ..-_- -F-{O------- -- --- _STATION DL•PTH — -' STATE MANHOLE REFERENCE - r U PERS REGISTRATION NO. I-' COUNTY - - ---- No DESCRIPTION OF WORK FEE —" --"- - TYPE OF CONNECTION.,.,... LENGTH FROM F HOUSE SEWER CONNECTING TO PUBLIC SEWER cq $ 3.50 I. ___.__CURB--_i -P` -_ `-1=._TO_P L.— �.... 111 _ _ -. -� HOUSE SEVER CONNECTING TO PRIVATE DISPOSAL SYSTEM 1.00_ _ ---------- --- - — - CONNECT ADDITIONAL BLDG. OR ~- - P NO. WOR USE SEWER 10Q Co. IMP, N0_� jr-12 NO, _ ALTER OR REPAIR EXISTING v iTRUNK PERMIT N0. ROAD PERMIT ND.`--------A--- OI< D,SPTRUNKDISCONNECT AND ABANDON SEWER STATE ENCROACHMENT AND/OR DISPOSAL SYSTEM 1.00 _ -- --- PERM T N0. t SEY ER OSAL SYSTEM I.D SEPTIC TANK. SEEPAGE PIT OR - .--. _---- --- --..----- I PITS_A_ND/OR_D14AINFIE_LD y�_00 WASTE cTRIAL PPROYAL CEaSPCOL-DRYW CLL- _ _ - SPECIAL CONDITIONS ONLY 2,00 CHARGES OWNER'S PE$NIIT CONNECTION CHARGE FE_ � 1! OO_ REIMBURSEMENTF. EEE I AUTHORIZATION L TOTAL FEE i 92 � -- I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED CON- TRACTOR 'IO CONNECT TH ABOVE DESCRIBED VKISTING DWELLING i APPROVALS DATE INSPECTOR'S SIGNATURE b� -- - - ----- --�.�-� .. ----- -'-----'---.- TO Tay PUBLIC - NEW HOUSE SEER SiG_SIGNED THIS�D Y CF ��- �• - �+ t'J_ - Ir OR CONNECT ADDITIONAL -- - �� O'11 15 AGEI 'R -¢ �d BUILDING OR WORK --��------= SEPTIC TANK, SEEP,PITS) ADDRESS--: _.,�.✓ _'"-'-- _ --� AND/OR DRAINFIELD - I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL.0 DRYWELL�f� AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING PLUMBING AND SEWERS, AIR.ALTER,RESEWAGE DISPOSAL PAIR, SFWFR OR I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/CR S LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE ABANDON HOUSE SEWER DESCRIBED. RESIDENTIAL PROPERTY, BACKFILL SEPTIC TANKS C SEEP. PIT($) 0 CESSPOOLS 0 SIGNATURE OF - - OF PERMITTEE WILLIAM J.FOX,COUNTY ENGINEER VALIDATION R.A.WOOD. CHIEF PLBG. INSPECTOR