HomeMy Public PortalAbout5842-5844 TEMPLE CITY BLVD_Sewer DEPAW MENT OF COUNTY ENGINEER. SEWER-SEWAGE DISPOSAL
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER BUILDING
ADDRESS
FOR APPLICANT TO FILL IN LOCALITY -
BUILDING NEAREST
ADDRESS CROSS ST.
LOCALITY DISTRICT NO. SERIAL NO. PERMIT NO.
NEAREST — -- -- -- A S
CROSS ST.
RECEIVED BY Ready for Inspection DATE ISSUED
OWNER
MAIL �---_--�__------ � -
ADDRESS USE ZONE OCCUPANCY MAP
-- I BK PG
CITY TEL.NO.
CONTRACTOR i
----�--- -- CO.IMP,NO.
ADDRESS
JOB N0.
CITY TEL.NO.
TRUNK PERMIT N0.
STATE
REGISTRATION NO. �J COUNTY ROAD PERMIT N0. -
LEGAL
DESCRIPTION LOT NO. STATE ,%RAAQH�EtIIT `
PERMI 0U #Ste #erm t 14 E},„•. t/ e
BLOCK TRACT INDUS 1 ;9 t ., ... s9 ... ix
SIZE OF LOT N0.OF 6tDGS. WASTE
NOW ON LOT CHARGES
USE OF
BUILDINGS CONNECTION CHARGE FEE
NO. DESCRIPTION OF WORK: FEE
HOUSE SEWER CONNECTING TO REIMBURSEMENT FEE
PUBLIC SEWER_ $ 3.50 RECEIPT NO. DATE I BY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLOC.OR EXCEPTION RECORDED
WORK TO HOUSE SEWER 1.00
ALTER OR REPAIR EXISTING NO- DATE 1 BY
SEWER OR DISPOSAL SYSTEM 1.00
--I DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1.00 CONNECTION.DATA
SEPTIC TANK,SEEPAGE PIT OR
_PITS AND/ORDRAINFIELD 2.04 STATION DEPTH
CESSPOOL—ORYWELL
SPECIAL CONDITIONS ONLY 2.00 MANHOLE REFERENCE
UPPER LOWER
TYPE OF CONNECTION LENGTH FROM
OWNERS PERMIT $ I 00 Y. CURB P.L. M.L.TO P.L.
AUTHORIZATION TOTAL FEE
I 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
SEPTIC TANK,SEEP.PIT(S)
ADDRESS..-..... .....................-•-••-._ -- AND/ORDRAINFIELD
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLI- CESSPOOL[:] DRYWELL E]
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
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED DISCONNECT PLUG AND
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOUSE SEWER
AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN-
ER OF THE ABOVE DESCRIBFJ GESIDENTAL PROPERTY. BACKFILL SEPTIC TANKS Ej
SIGNATURE SEEP.PiT(S)E3 CESSPOOLS
OF PERMITTEE-.. ........_ «:, --------•-••----
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