HomeMy Public PortalAbout5811-5811 1/2-5813TEMPLE CITY BLVD_Sewer (2) CEA8 2/7;
76A 642D APPLICATION FOR PERMIT
• COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION
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JOHN A. LAMBIE. COUNTY ENGINEER ADORE7COLEMAN W. JENKINS. SUPT. OF BUILDING
LOCALITY
R APPLICANT TO FILL IN NEARESTCROSS ST.
(PRINT OR TYPE ONLY)
LEGAL——
DESCRIPTION LOT NO OWNER
BLOCK TRACT ADDRESS
NO. OF BLDGb. TEL. NO.
SIZE OF LOT ON LOT CITY
USCo-F- -
BUILDINGS DISTRICT NO, OUR CLASS PAA P •---RROCESSED BY
a K P,
GONTRACTOR
ADDRESS CONNECTION DATA
CITY TELNO.
STATION DEPTH
.
STATE LIC Li ER
LICENSE NO. CLASS MANHOLE REFERENCE LOWER
DESCRIPTION WORK FEE TYPE dl'�ONNECTION LENGTH FROM
------
HOUSE-T- Y P.L.ROUSE SEWER CONNECTING TO ClAkEM.L.TO P.L.
PUBLIC SEWER $5.00 P.C.NO.
LSEPT 417 CA E Pal rcxp-, CO. IMP. 0.
ITS AND/OR DRAINFIFLD $10.00
HOUSE SEWER CONNECTING TO
TRUNK PERMIT N ----IRDL�,D PERMIT NO. >-
F'RfVATF DISPOSAL SYSTEM @ $3 00 0-
CONNFCT ADDITIONAL BLDG wmWrwjc�s� RECORD,INST-R,NO 0
OR ATE
WORK TO HOUSE SEWER @ S3.00 I
OVERFLOWS�E-EF�AGF PIT76RAINIFTELD
EXTN,,CESSPOOL,DRYWELL.MANHOLE @ $5.00
Y, .
ALTER. HWOR STWIDENING REPAIR OR ABANDON HOUSE 0
SEW-P-R 0*DISPOSAL SYSTEM -0 -.$3.00
t
STATE.ENCROACHMENT Q
PERMIT NO LLL
INDUSTRIAL
WASTE APPROVAL
OViNER'S CHARGES
PERMIT $1 -3 00
AUTHORIZATION I TOTAL FEE CONNECTION CHARGE FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HERE!N NAMED CON- REIMBURSEMENT FEE
TRACTOR r 0 C ONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO T H E P USLIC SEWER. APPROVALS i ATE_��SPECTOFV.SIGNATURE
�
SIGNED THIS-DAY OF --19-
OWNER OR NEW HOUSE SFWER
OWNERS ACENT-- CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS
SEPTIC TANK. E EP,PIT(5).
HEREBY EREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND,OR DRAINFIELD
IELD
A N C STATE THAT THE
E ABOVE IS CORRECT AND AGREE TO COMPLY
W:T H ALL COUNTY nRDfNAN(7ES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL El URYWELL El
LENSED
CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER.REPAIR,SEWER OR
L�C E NSED AS REQUIREDLOS ANGLES COUNTY AND STATE'OF SEWAGE DISPOSAL SYSTEM
By
C I I
AL IORN A OR THAT I AM THE LEGAL OWNER OF, AND INTEND 70 -61SCONNiCT PLUG AND
JOE HO
RES IN, THE ABOVE DESCRIBED RZSlf)rNTlAL PROPER7Y, kBANDON _USE SEWER
SIGNATURE".
OF PERMITTEE BACKFILL SEPTIC TANKS
SEEP,PITS)
CESSPOOLS
VALIDATION JACK R. ALLEN
SUPERVISING MECHANICAL ENGINEER
CK. M.0. CASH
Lito 6 9, 4 jtL 13 1 0 D 6.0 0-