HomeMy Public PortalAbout5728 CAMELLIA AVE_Sewer__ DEPARTMENT OF OOUNTY ENGINEM SEINER—SEWAGE DISPOSAL 1
DMSION OF BUELDING AND SAFETY PERMIT APPLICATION
OOUNTY OF I.08 ANGEL
WILLIAM J. FOX, CDUI4TY gNDIIN[ER BUILDING f
ADDi,
FOR APPLICANT LOCALITY
BUILDING NEAREST
ADDRESS ORO 84 ST. r�
LOCALITY
DISTRICT NO. SERIAL MC. PERMIT NO.
NEAREST A 9CRO8S ST.
RE IVED BY Maly hr Iaspwtl*■ DATEISSUED
OWNER
MAIL ONE OOOUPANCY M.Ar
ADORE SS / BK re
CITY TEL
00W.AETONottinQham rA- of 5n-
Cal GO.IMF.MCL
ADDRESS 5933 N. CLOVERLY AVE. JOB.No.
CITY TEMPLE CITY, CA4� Na
TRUNK PERMIT NO.
{TATE
REGISTRATION NO. COUNTY ROAD PERMIT NO.
LEGL
DESCRIPTION LOT NO. STATE ENCROACHMENT
PERMIT NO.
BLOCK TRACT 6 INDUSTRIAL
WASTE APPROVAL
SIZE OF LOT y N0.OF BLOBS, CHARGES
NO ON MT 21
USE
BUILDDI NGS CONNECTION CHARGE FEE
NO. DESCR PTIDN % R EE
REIMBURSEMENT FEE
HOUOESEWERGONNECTINGTOk-47
PUBLICSEWER 0 111 S..64 RECEIPT NO. DATE BY
HOUSE-SEWER CONNECTING TO
PRIVATE DI8POGAL SYSTEM I M
OT D ION B EXCEPTION RECORDED
WORK TO HOUSE SEWER I dS NO
AL E OR PAIR I ING DATE BY
SEWER OR DISPOSAL SYSTEM I.M
DISCONNECT AND A13ANDON SEWER
AND/OR DISPOSAL SYSTEM 1.00 CONNECTION DATA
B PTI TAN .
SEEPAH PITR i
PITS AND OR DRAINFIELD !AO STATION 3t , DEPTH
ESBPOOL--0RYWELL
SPECIAL OONDITIONS ONLY 2-007 f M mHolLEUPPEREFERENCE
TYPE ECTION LENGTH FROM /
OWNERS PERMIT 1 Y. OUR P.L. M.L.TO P.L
AUTHORIZATION TOTAL FEE
I HAVE DATEWITH THIr HvRlN NAMED
CO TRACTOIR TO CONNECT�TH�E ABOVE DESO11BEDAMSTINQ APPROVALS INSPE R•S SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER
NEW HOUSE SEWER
SIGNED THI DAY OF � 19- � �
OWNER OR CONNECT ADDITIONAL
OWNERS ABET BUILDING OR WORK
ND
BE l0 TAN
KK,,SEEP.PIT(S)
ADDRESS AOR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAV[ READ THIS APPU- OESSPOOL❑ DRYW[LL
CATIONAND STATE THAT THE.ABOVE IS CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STAT[ LAWS ALTER.REPAIR,SEWER OR
REGULATING PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED DISCONNECT PLUG AND
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOUSE SEWER
AND STAT[ OF CALIFORNIA OR THAT I AM THE LEGAL OWN-
[Q OF THE A13OVE DESOBIIB�ED R=D[NTIAL PROPERTY.
81GNATURE M. NOTI MHA C OF S0. SEEP.PIT(I)[] CESS-00
OF PERMITTEE
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