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