HomeMy Public PortalAbout5920 TEMPLE CITY BLVD_Sewer 7E66a 11.75B&>-eeAPPLICATION FOR PERMIT 1
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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
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