HomeMy Public PortalAbout5650 CAMBURY AVE_Sewer__ ; TEMPLE CITY
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CES08 e�68 APPLICATION FOR PERMIT GI
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COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL 2115
DEPARTMENT OF COUNTY ENGINEER /
BUILDING AND SAFETY DIVISION BULDInG b I — U
ADDRESS )
CAOA. LAMSIE, Count, Engineer
SATT D. GRIFFIN, Supt of Building LOCALITY 7TiFFM LE' /Jr .
NEAREST L I 1 L L
FAOR APPLICANT TO FILL IN CROSS ST./Q ^ / ^, - !f !
ALLOT ED
f / ft C I_O ' OWNER gi9-fi VQ LI T (j1P6c
TION TRACT I ••7 I / / e A^,1 / MAIL 10 'J J..,ADpRE3 UN0.OF BLDGS. /-
LOT �l] Q NOW ON LOTCITY 2M �� / (., ryp.i ^ '�GS V L 'V DISTRICT NO. R MAP PROCE EO BY
BKPG
CTOR21S CONNECTION DATATEL. STATION DEPTH
STATEMANHOLE REFERENCEATION NO. COUNTYDESCRIPTION OF WORK FEEOUSE SEWER CONNECTING TOUBLIC SEWER - @ $3.00 TYPE OF CORNECTIO LENGTH FROMEPTIC TANK,SEEPAGE PIT OR T. CURB P.L. M.L.TO P.L.
PITS AND/OR DRAINFIELD @ S3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN.. CESSPOOL. DRYWELL @ S2.00
HOUSE SEWER CONNECTING C.N0.
PRIVATE DISPOSAL SYSTEM @ 41.00 LT -I/B�TMP !OB NO.
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT N0. ROAD PER
WORK TO HOUSE SEWER @ $1.00
ALTER, PAIR OR ABANDON HOUSE - STATE ENCROACHMENT
_ SEWER ORREOISPpS LBYSTEM @ $1.00 PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT S Z DO CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE 0.0 REIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE, DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS DAY OF 19_ NEW HOUSE SEWER
OWNER OR - CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
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 REGISTERED AND/OR DISCONNECT PLUG AND
_ LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM THE LYE6 ER OF T ABOVE
DESCRIBED RESID IAL PROPERTY. BACKFILL SEPTIC TANKS ❑
SIGNATURE
SEEP.PIT(B ❑ CESSPOOLS
OF PERM1iTE �
VALIDATION, ROBERT A. WOOD
CK. M.D. CAStl SUPERVISING MECHANICAL ENGINEER
A.
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