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HomeMy Public PortalAbout5920TEMPLE CITY BLVD_Sewer (2) 76A6420 E=£�3 l2.58 APPLICATION FOR PERMIT 7 Fi& ■ DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL 11�! Department of County Engineer County of Loa Angeles BUILDING WM. J. FOX, COUNTY ENGINEER XY ADDRESS ��,+' ,�'. " CASSATT D.GRIFFIN, SUP'T OF BUILDING LOCALITY ✓r°g , FOR APPLICANT TO FILL IN `NEAREST 4F ' CROSS ST. LEGAL _DESCRIPTION LOT NQ., "',r✓" OWNER BLOCK TRACTMAIL SIZE OF LOT_'}. fW ''s NOWOONBLOTS� F y _.i yc_ CITY _ ,..- TEL.NO. USE OF � DISTRICT NO. GROUP MAP Co. BK PG 14 CONTRACTOR dia .W w�.(;'L s.Lne-5. �.� Co..L.fie 6o. ADDRESS 5933 'i 1 C1te•rly ilye. CONNECTION DATA 'CITY 'emp Ley TEL. NO. ,L'��O«»8-�-j"-_30 STATION DEPTH .� STATE -- -- - MANHOLE REFERENCE REGISTRATION NO. 147012 L'7- COUNTY UPPER TYPE OF CONNECTION LENGTH FROM NO. ( DESCRIPTION OF WORK FEE Y._ csdzB- _ P.L_ _ M.L,TO P L. t. -- € HOUSE'S VIER CONNECTING TO PURL C SEWER _ _ k $_3.50 �__.__-�`.� 1 KCUS£ EWER CONNECTING TO -- --- ".� PrcIV,ATE DISPOSAL SYSTEM 9.00 -'----- -- i CONNECT ADDITIONAL BLDG. OR �—'--� .�. CO. IMP. NO. - JOB. NO. i WORK TO HOUSE SEWER _----. 1,00 '__-I,,^.____. ---- AaTER OR REPAIR EXISTING - SEWER OR DISPOSAL SYSTEM. 9.00 I TRUNK PERMIT NO. ROAD PER,1d1T NO. DISCONNECT AND ABANDON SEWEP. STATE ENCROACHMENT AND/OR DISPOSAL SYSTEM1.06 I �� PERMIT NO. SEPTICTAtdK SEEPAGE PIT ORY PITA AND/OR DRAINFIELD2 00 1NDUS'TRIAL --..� CESSPO W ELL WASTE APPROV",L OL DRY "+ SPECIAL CONDITIONS ONLY 2.00 I ? CHARGES € i -`-`--' - CONNECTION CHARGE FEE OWNER'S _PERM P $__—i 00 AUTHORIZATION _ TOTAL FEE i `� E REIMBURSEMENT FEE a I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED CON•. APPROVALS DATE INSPECTOR'S SIGNATURE TRACTOR TO CONNECT T;If ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC S VdER NEW HOUSE SEWER SIGNED THIS._— DAY OF 9✓✓ OW'tdERCR CONNECT ADDITIONAL O`W'NERS ENT - - BUILDING OP.WORK _ _-��— •— SEPTIC TANK, PIT (S) PIS) ADD E _AND/OR DRAINFIELD I HEREBY ACKNOWLEDGE THAT I HAVE R AD THIS APPLICATION CESSPOOL D DRYWELL❑- AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING PLUMBING AND SE`WER$. ALTER, REPAIR,SEWER OR I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR SEWAGE DIS_POSALSYOR LICrNSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF NSCONNECT PLUG AND CALIFORNIA OR THAT i AM THE LEGAL OWNER OF THE ABOVE _RAN DON Pio ISE SEWER - OESC IBED,.pc5lDE�N;,i1AL FROPERTY<< r_y BACKFILL SEPTIC TANKS[I SIGNATURE `v�S r. SEEP.PiT(:S) � CESSPOOLS -� � SI OFPERMITTEE. WILLIAM J. FOX, COUNTY ENGINEER VALIDATION BY BY DEPUTY DEPUTY BY BY b DEPUTY DEF UTY