HomeMy Public PortalAbout5733AGNES AVE_Sewer TEMPLE CITY
0
CE808 8 89 APPLICATION FOR PERMIT
E80B
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTYLDIMS�ILO�N
INEER
BUILDING AND SAFETY BUILDING
ADDRESS�'
JOHN A LAMBIE County CASSATT D GRIFFIN Supt LOCALITYMMMMJNEAREST
FOR APPLICANT TO IN CROSS ST.
LEGAL
DESCRIPTION LOT NO JQ. (? � OWNER
BLOCK , TRACT v MAIL
ADDRESS
SIZE OT NO OF BLDGS
Q NOW ON LOT 1 CITY TEL NO
USE OF
BUILDINGS ./ �' ' DISTRICT NO GRUPMAP P C D BY
CONTRACTOit » � 7 / �"K ,r ; I
ADDRESS CONNECTION LDAAI
CITY � � TETEL'NO �� �� STATION � �r DEPTH
I
REGISTRATION NO ®COUNTY STATE MANHOLE REFERENCE /
LOWER
No DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
f PUBLIC SEWER @° -$3-00 TYPE CTION LENGTH FROM
SEPTIC TANK SEEPAGE PIT OR Y CURB P L M L TO P L
PITS AND/OR DRAINFIELD @ $3 00
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL @ $2 00
HOUSE SEWER CONNECTING TOP C NO
PRIVATE DISPOSAL SYSTEM @ $1 00 CO IMP NO JOB NO
WORK TO
CONNECT
HOUSE ISEWERBLDG OR @ �1� O TRUNK PERMIT NO ROAD PERMIT NO
ALTER REPAIR OR ABANDON HOUSE
$T� STATE ENCROACHMENT
SEWER OR DISPOSAL SYSTEM @ $100 PERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT $ 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE 1j /��„) _ REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREINXAMED CON
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPE 0 SSIGNATURE
TO THE PUBLIC SEW
SIGNED THIS —DAY 0 19 `' NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT '� � �--'� i�Z BUILDING OR WORK
ADDRESS- 5 %� ,1��— f SEPTICTANK SEEP PIT(S)
AND/DR DRAINFIELD
IHEREBYA61KNOWLEDGE THAf 1 HAVE READ THIf APPLICATAfN
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL ❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT I AM PROPERLY ISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES CQQUNT NO
STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM THE LEG DOWNER 0 THE ABOVE
DESCRIBED RESIDENT L PROPERTY�/ BACKFILL SEPTIC TANKS ❑
SIGNATURE SEEP PITS ❑ CESSPOOLS
OF PERMITTE r �
94 ROBERT A WOOD
J 6AUDATION
y p CASH SUPERVISING MECHANICAL ENGINEER
fil9 9 4 6 Q SEP 0 1 0 0 10.0,0-
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