HomeMy Public PortalAbout5817TEMPLE CITY BLVD_Sewer (2) 4 � J
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6A642D A,PPLICATIC7N. FOR PERMIT �y
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
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DEPARTMENT OF COUNTY ENGINEER
BUILDING .AND SAFETY DIVISION
JOHN A, LARIf3IB, County Engineer e 4k
WILLIAM A. JENSEN, Supt of gu lding
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FOR APPLICANT TO FILL IN
DE5"PIE 7..N
LOT NO L ' Ov ".tER
M;._
BLOCK TRACT ZL C+RESS
NO. OF BLDGSo
SIZE 01 LOT NOW ON LOT CI fY 7EL. NO,
USE O
BUILDINGS DiS7Ri CZ'NO. GRO41F% MAP PROCESSED BY
CONTRACTOR .+•' .1^e_ ia.--. _ �C f _ J` w �- ' <
AbDRESS Ls C�NNECTIONT'ATA
t �I' ef - STATION DEPTH - -
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STATE
REG STRA..ON NO. pl�+3YCOUNTY MANHOLE REFERENCE
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DESI RIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SE NER CONNECTING TO T Y. CURD P.L. •`M'L_70 P,.I_. -
PUBLIC_.'SFWER `@ $5.00 P.C.NO.
5 I __._ ---_.—
� __._-_ ;F'PTIC TANi( SE EF.AGE PiT OR --�-_-
S ITS AND OR ORAINF FIELD $10.00 CO. IMP NO. JOS NO.
7T170USE SEW ER CONNECTING TO ------ � TRUNK PERMIT NO. ROAD PERMIT NO,
PRIVATE.DISPOSAL SYSTEM $3,00
-�CONNECT DDITIONAL BLDG.OR -- -- AFFi DAVIT WAtY CRI [*sim h'�- RECORD INSTR.NO. DATE
WORK TO HOUSE,SEWER $300 i
--
UVERFLOW SEEAAGE PIT DRQ INFIELD
1 EXTN CZ SPOOL.DRYWFLL MANHOLE @ 55.00 -__ .._ HW' OP 3'I'' WIDENING; �.
ALTER-RZPAiR OR ABAi^)F70 OUSe ._.,
1 SFWFR O!31 SPOSA SYSTEM ..___@_$3.00 r STATE ENCROACHMENT T -
----- -— n?RMIT NO.
—_...----- __._..__.__�'.�_._.._,.____._- INDUSTRIAL
_ _..WASTE APPROVAL
OWNER'S PERMIT l 21 oa ------- — --- -- ---- -- -- .
AUTHORIZATION TOTAL FEE g',. I2;)c
� .� CONNECTION CHAF2GE F'�EE
.1 HAVE AT THIS DATE A CONTRACT WITH THE. HEREI V NAMED CON- REIMBUR5EME NT-FEE
TRACTOR 'TO COtd NECT THE ABOVE DESCRIBED EXISTING DWELLING - - —� EE---- -'-- ---- -- -
TO THE PUBLI Cop" APPROVALS DATE I INSPECTOR,. SIGNATURE
SIGNED THIS----DAY OF--------I9--
OWNER
F------ --_.19---OWNER OR NEW HOUSE SEWER
-- ---
OWNERS AGENT_-______—._ CONNECTADDITIONAL
.BUILDING OR WORK
SEP
--i HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION AND,'OR DRAi'NFIELD
O TANK,SEEP,PIT(S) I
AND ;TATE THAT THE ABOVE: 15 CORRECT AND AGREE TO COMPLY AND,' j
WITHALL. 'O- UNTY ORDIINANOES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL (_; DRYWELL � I
i HEREB'V CERTIFY TfiAl" 1 AM PROPERLY REGISTF'RED AND/OR A7„TE:F7 1'F_r Ai•R SEWER 7t I LICENSED AS REQUIRED BY LOS ANGLES COUNTY .AND STATE OF IE�vi;'. : UISPOS:AL:S-YS7EM -
RESP N t'HE A .0g*f S H,SIp£NT`LPUPER'j' SBE)'. P;'i57 ❑ CESSPOOLS b
('oLiFaFINIA OR THAT IyA�.M� THE LEGAL OWNER C AND N I
S!G NATURE t;AC KS
OF PFRMITT FF i�.+� "3 -.
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VALIDATIO-N ROBERT A. WOOD
C K. O ,%,SFT
SUPERVISING MECHANIC-'AL ENGINEER
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