HomeMy Public PortalAbout9560 BROADWAY_Sewer__ ]fiA 692D - CE808 - 9/73 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING s 9560 Broadway
BUILDING
T
LOCALITY Temple Cit
FOR APPLICANT TO FILL IN =AOSSSST. Temple City Blvd.
LEGAL ^ T.i...
DESCRIPTION LOT NO.
� �(.,A, � 0 OWNER M . & Mrs . Ben Gabriel
BLOCK TRACT S /(�(/.//y4n.��'�/ `���� MDDRESS P.O.BOX 244NO. OF
SIZE OF LOT NOW ONB LOTS CITYTem le City y TEL. „D. 443-2582
USE OF DISTRICT N0. GROUP MAP PgOCE 5 D BY
BUILDINGS ,BK P�^a/
GONTRACTORLazy Drains Co . "� V �� U 13
ADDRESS P.O.BOX 254 •� •'/ CONNECTION DATA
CITYPasadena Ca TEL. NO. /9 /-4411 STATION '1 &3 DEPTH •/
STATE 263965 LIC CY12 MANHOLE REFERENCE LOWER/
VV UPRER-
TATE
NO. ,LABS 'Y
NO. 1 DESCRIPTION OF WORK FEE TYPE OFC N ON LENGTH FROM
HO USE SEWER CONNECTING TO ( T. .'� CURB P.L.
PUBLIC SEWER Eq $J.00 I
SEPTIC TANK.SEEPAGE PIT OR •.v P.C.NO.
PITS AND/OR DRAINFIELD BI0.00 CO.IMP.NO. dam• JOB NO,
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 6 53.00 TRUNK PERMIT NO. ROAD PERMIT NO.
CONNECT ADDITIONAL BLDG,OR AFFIDAVIT My U3EMOI RECORD.INSTR.NO. DATE r,
WORK TO HOUSE SEWER ® $3.00 O.
OVERFLOW SEEPAGE PIT..DRAINFIELD,
EXTN..CESSPOOL.DRYWELL -Q $500 U
ALTER.REPAIR OR ABANDON HOUSE HWY.OR ST,WIDENING C
SEWER OR DISPOSAL SYSTEM ® 53.00 STATE ENCROACHMENT O
MANHOLE ~ Q $J,00 PERMIT NO. V
W
INDUSTRIAL
.'v`.�._�,._'ER • WASTE APPROVAL Z
OWNER'S PERMIT f CHARGES
AUTHORIZATIONJ TOTAL FEE CONNECTION CHARGE FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED COIN- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. APPROVALS DATE INSP To, S SIGNATURE
SIGNED THIS DAY OF 19_ j "
OWNER OR NEW HOUSE SEWER
al
OWNERSAGENT CONNECT AODITI ONAL
BUILDING OR WORK
ADDRESS
I HEREBY ACKNOWLEDGE THAT, 1 HAVE READ THIS APPLICATION
TANK,SEEP.PIT(5)
TION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE.To
COMPLY
WITH ALL"COUNTY�•ORDINANCES'AND STATE LAWS REGULATING E '
PLUMBING AND SEWERS. •. I CESSPOOL ❑ ,DRYWELL ❑ '
I HEREBY .CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR ALTER.REPAIR,SEWER OR
LICENSED AS REQUIRED BY 5 ANG, OUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFCANIA OR THAT IA LEGA O NER F• AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABOV HIED SI ENT I P PERTY. ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PEYMTfEE SEEP.PIT(S) ❑ CESSPOOLS ❑
VALIDATION ro "SCK. M.D. CASH
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