HomeMy Public PortalAbout5920 TEMPLE CITY BLVD_Sewer (2) 76A6420
E=£�3 l2.58 APPLICATION FOR PERMIT 7
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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