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HomeMy Public PortalAbout5920TEMPLE CITY BLVD_Sewer 7E66a 11.75B&>-eeAPPLICATION FOR PERMIT 1 a� DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL Department of County Engineer County of Los Angeles BUILDING JOHN A. LA.MBIE, COUNTY ENGINEER _ADDRESS 3 CASSATT D.GRIFFIN, SUPT OF BUILDING LOCALITY NEAREST FOR APPLICANT TO FILL IN CROSS ST. LEGAL ------- - -- -- — -. - - - - - __ DESCRIPTION LOT NO. OWNER - BLOCK TR.4 C.T MAILAfLADDRESS _ --- -..�----_-.—.— N0. OF BLDGS. -- -CITY � - --: TEL. N0. N SIZE OF LOT _ _ OW ON LOT _ USE OF — — '-- MAP DISTRICT NO. GROUP BUILDINGS BK PG -CONTRACTOR- ADDRESS CONNECTION DATA CITY y_- -- TEL NO. STATION l _i i',a _ DEPTH MANHOLE REFERENCE _ UPPER v STATE �.-..—_�-._.- ----- — LOWER REGISTRATION NO. COUNTY _ No. I DESCRIPTION OF WORK - FEE ---- ---- ---------- ----------- - -- _I --- - ---- - _ -- ----- j ---- TYPE OF CONNECTION LENGTH FROM - HOUSE SEWER CONNEC ING TO ! Y CURB +x.L.. M r_._TO PUBLICSEWER _ _ @ $3.50 ----- -- j SEPTtC TANK,SEEPAGE PIT OR -- ��T--- v v r j Pl S AND/OR.DRAINf E.D !� S 3.00 ( ..,: � •�`. .���s.,: "9 - .<�d - I OVEArLOW SEEPAGE PIT,DR41NI"EELD C.O._IMP, NO, JOB.NOO I EXTN ,C SSPOOL,DRYW LL,h 4NHOLE �t ^ ....00-� ----- - --_I --- ----^------ --.---- HOUSE SEWER CONNECTING TO PRIVATE DT:SPOSAL SYSTEM (.r ¢?.00 I _J 'TRUNK PERMIT NO. ROAD PERMIT NO.. CONNECT ADDITIONAL BLDG OR —- ._ r__.—._ _ --------------_---_ —STATE ENCRCACHMENT ENCRCACFIMENT WORK TO HOUSE SEWER f' S;.00 � PERMIT NO. - r ALTER,REPAIR CP.ABANDONHOUSE �--� SEINDUSTRIAL-- ------ ---- ----- --- SEWER OR DISPOSAL SYSTEM 1. .C� I � � . '/,'ASTE APPROVAL . CHARGES CONNECTION.C•iARGE FEE OWNER'S PEWIT TOTAL SEE AUTHORIZATION ATI®I - ( -_j i REIMBURSEMENT FEE `. / APPROVALS � DATE j IN5PEC'Gr �SIGNATURE I :HAVE AT Tt{IS DATE A CONTRACT WITHWITHTHE APP HEREIN NAMED CON• -- --_---_—__-_— TRACTOR _--_-1_-.----_--J,__-.-- TO CONNECT THE ABOVE U�SCRIDE BED S'(INrD1VEl.LI•N� � -.---- ---_----- __D EX_.lI i TO THE P U3Lt SEWER- ., NEW HOUSE SEWER j SIGNED THIS a ^« �L� ig R�r CONNECT ADDITIONAL _ DAY OF (`6'VNER OR +' +� UILI`I r OR'N OWN.rRS9"-la.. SEPTI(,.TANK,SEcP' NT(S.) _.._ j ADDRESS_ ._..__- AND,OR DRAINFFL .--.—_ ;---;'-- -' . . _ _..-- D I HFZRBY ACKNOWLEDGE THAT' ! HAVE READ .,HIS APPLICATION CESSPOOL!- DRYWELL[] AND STATE. THAT PSL.-ABOVE 15 CORRECT AND AGREE TO COMPLY WITH ALL -COIJNTr' ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR II i PLUMBING A14D S WER$$, SEWAGE DISPOSAL SYSTEM I HER BY CERTIFY THAT I AM PROPERLY REGISTERED. AND'OR DISCONNECT PLUG AND j I LiCE°V F AS REQUIRED BY Loa ANGELES COUNTY AND STATE CF � CALIFOP vin. OR FHAT' I AN". THE LEGAL OWNER OF THE ABOV. ABANDON HOUSE SEWER DE.SCR,BED RE D6NI IL PROPERTY "n RACKFI L 5 EPT TANKS SIGNATURE t :3 a�4y SLE_P. PIT r L] CESS P0 LS - ---- ---... -- OP PERMITTEt1t:.*s..{t'+',5 i JOHN A. LAMBIE, COUNTY ENGINEER i, ALIDATnp,,�pp��' -'ROBERT A. WOOD,CHIF PL.BG. INsPECTOR 1.A5 -