HomeMy Public PortalAbout5842-5844 TEMPLE CITY BLVD_Sewer (2) A
E808
10-63
6A 542 D APPLICATION FOR PERMI
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER SEWER—SEWAGE DISPOSAL Ll
BUILDING AND SAFETY DIVISION 11U,11-DING
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JOIHN A. LAMBIE. County Engineer '.R'SS
WILLIAM A. JENSEN, Supt of Building
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FOR APPLICANT TO FILL IN RO
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DESCRIPTION LOT NO OWNER
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LOCK -RACT T MAIL
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ADDRESS
I
NO. OF BLDG S.
SIZE OF LOT NOW ON LOT TEL. NO.
BU'LD N "4,V, DISTRICT NO, GROUP MAP
PROCESSED 5Y x
BK PG
CONTRACTOR
P
10D
ADDR _.lye
.ESS s CONNECTION DATA
1 E L, N0.L% (ji !iN S T A r 101 N DEPTH
STATE MANHOLE REFERENCE
REGI-STRATTON NO.C_ COUNT OWER
C_ FEE
]F�CRIPTIC)N - TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO CURB P.L. M.L,TO P.L.
PUBLic SEWER
P.C.NO�
.5 CPT fC T 4 IN K-SF E_Fl A G EP TT 0 R
PITS AND/OR DRAINNELD S10.00 CO IMP. NO. JOS NO.
HOUSE SEWER CONNECTING_T6
PRIVATE DISPOSAL SYSTEM 3.00 TRUNK PERMIT NO, ROAD PERMIT NO.
CONNECT ADDITIONAL BLDG CR $
--kVF- M T-M Re
FI 6 7; ITER �FMEST ORD. (NSTR,NO.
DATE
WORK TO HOUSE SEWER @ $3,00
EXTN.,CES$FOOL,DRYWELL,MANHOLE @ $5.00, HWY.OR ST.WIDENING
X6A_N_DO_N HOUSE
-TEEN— C_WMENT
DISPOSAL SYSTEM @ 53 0o -ST lil-A
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� -1" -;-" I
PPERMITNO. c
f
INDUSTRIAL
WASTE APPROVAL Jj
CHARGES
OWNEWSPiRMIT 2] 00__
CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE
A HAVE AT THIS DATE A C'ON'TRACT WiTH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRA CT R T CONNECT THE ABOVE DESCRIBED EXISTING DWELL?NG
APFR_OV___ _T_.ATE IN.PECTOR'S SIGNATURE
0 0 — '
TO THE P LJBLiC SEWER, ALS
SIGNED THIS-DAY
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OWNEROR NEW HOUSE SEWER
OWNERS AGENT-
CONNECT ADDITIONAL I.
ADDRESS BUILDING OR WO
T_
SEPTIC TANK SEEP,P(T(S)
I HFRERY ACKNOWLIEO�,E THAT I HAVr. READ THIS APPLICATION ANO,OR GRAINFIELD
'I'L, S I HE AHDVCr AND AUREE FO COMPLY
,ATE THAT !� CORRECT
Wj'H COUNTY COUNTORDINANCES AND STATE LAWS RFGULA*!ING
P�LU M.8 ING AND SEWERS
RS. CESSPOOLn "RYWEI_L D
HERE BI' CERTIFY THAT I AM PROPERLY REGISTERED AND.'OR ALTER,RE'AIR,SEWER OR
C.CEN'FO AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF AND INTEND TO
RF51r
_)E IN, THE -_S.,kVE D—CRIBED RES!DEN U S 0
ABANDON HO E:SEWER
BACKF ILL SEITIC TANKS StQNATURC
OF FERMITTEF
kJ
VALIDATION ROBERT A. WOOD
CK._� M.0. CASH SUPERVISING MECHANICAL ENGINEER
LALO 7 2 1 7r. N10-11 9 5 0 5,0 Q-