HomeMy Public PortalAbout6121 CAMELLIA AVE_Sewer__ C
C6808108
r5AB4tD APPLICATION FOR PE MIT
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COUNTY of LOS'AXGFT- SEWER—SEWAGE DISPOSAL
D$PAHTr[IT .OF COUNTY ENGIN]EE]a
BUILDING AND SAFETY DIVISION 9mo
r0 A, LA.It, Glom EB WMa A. IE OM,FOE APPLICANT TO FILL IN DESCRIPTION LOT NO. 0
MAIL
SLACK TRACT ADDR[SM
ND. of LDGB.
*IXX OF LOT NOW ON LOY Y 6I-fY TEL. NO2
USE OF DISTRICT NO. OROUF MAP PROCESSED OCSED►Y
■U ILDIMM,
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CONTRACTORS%D
ADDRESS NNECTION DATA
TEL, NO. s NATION —P—
fTATIUrPQt
REGISTRATION NO. COUNTY MANN OL[R!F[R[NC6
No. DEHCRIPT'IQN O WORK FEE TYPE OF LENOTTI FROM
HOUSE SEW[11 CON [CTI NQ TOY,
CURB P.L M.L TO?-.L-.PUBLIC SEWER 0 tB.DO J 0O P.C.NO.
SEPTIC TANK,atifpAqK irT 04R CO.IMF,NO, 10■NO.
FITW ANO/OR DRAINFIELD 41 {10.00
HOU{[SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PEIIMLT NO. CL
PRIVATE DISPO*AL SYSTEM O $3.00 (�
CONNECT ADDITIONAL B DO.OR AFFIDAVIT I •Amf WUIUT ""CORD.INSTR. D^TE LLVrrJ
WORK TO HOUSR SEWER 0 4S.00
OVERFLOW{[[PAGE PIT,DRAINFIELD
EXTN.,CEId FOOLDgYWELA-MANHOLE 0 $15.00 h
AL R.R FAIRS TE
A NDO U■ HWY. OR ST.WIDENING .y
YEW[R OR DISPOSAL YSM 7.00 STATE ENCROACHMRNT L
PERMIT NO.
INDUSTRIAL
WASfE APPROVAL
CHARGES
OWNER'S PEBMTf s s 00
AUTH0BUZ*TIOv TOTAL
FE CONNECT ION CHARGE F[[
R
'I HAVE AT TWIN DATE A CONTACTL WITH THE HEREIN NAMED'CON- REIMBURSEMEkT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED &SIFTING DWtLLING
TO THE PUBLIC JVSNMfr � APPEOVAIS DATE INSPECTOR'S SIS NATURE
810NED TH115 DAY OF / f a�` 19
QWNER OR NEW HOU{[SEWER
OWNERS AMR CONNECT ADDITIONAL
BUILDING OR WORK
ADDRi�f
J HERESY ACKNOWLEDO■ THAT 1 HAVE READ THE' A ICAYION ■ TANK.69111.0,FIT(S)
AND T
STAT[ THAT H[ ABOVE If CORRECT AND AGREE TO COMPLY ANDND/OM D1tAI NlIELD
WITHALL COUNTY ORDINANCES AND STATE LAWN REAULATINO
FLU MB ENO AND SEWERS. CSSSFOOL ❑ DRYWELL ❑
I HEREBY CERTLFY THAT I AM PROPERLY RRMI"RRD AMD/OR ALTI1 R,REPA IR,■EW IR OR
LICINOID AN REGWIRED BY LOS ANGLE► COUNTY AND (TATE OF SEWAGE DISPOSAL BYSTEM
CALIFORNIA OR THAT 1 AM TZKO PWNEk OF. AND INTEND TO pISCONNECT PLUG AND
REBID[ IN, THE ABOVE D I RESIDENTIAL PROPERTY. ABANDON HOUSE SEWER
SI O N ATU R[ ry
OF PERM ITT[I f BACKFILLS[FU TA N KS r-Y !a
eIv.FIT(f) LJ CEYaroou L/
JA
VALIDATION ROBERT WOOD
SUPPRVIHINO MECHAA NICAL ENGINEER
CK. M.O. CASH
3 8 3 51 T28 1 0 D 7.00-
COUNTY OF LA9 ANGELES TF;MPLE CITY 0508 SEVER PERMIT
DEPARTMENT OF PUBLIC FORKS 9701 LAS TUNAS BE 0508 1207020006
BUILDING AND SAFE'T'Y / LAND DEVEUJPMENT TffiXPLE CITY CA 91780
PHONE: (626) 285-0488 ETT:
LEGAL ID: SEWER SEPTIC: SEWER BDZIa ZNG ADDRESS:
TR: 13277 LT: 7 EXIST OCC GRP: 6121 CAMELLIA AV
BLDW. NOW ON LOT: _ TF311P CA 917801734
ASSESSOR INFORMATION NUMBER: CONNECTION TYPE: NYAREST CROSS Ste': TEXPT•R CITY
5385-015-013 ORIGINATION: _ THOPAS PALE: 596 GRID: J2 LACALITY: TE34PLE CITY, C
LEN(M ML TO PL: - STATION: DEPTH:
TENANT: l4ANHOLE REFERENCE: UPPER/LOITER: ISSUED ON: PROCESSED BY:
07/02/12 SR
COUNTY IMPROVEMENT NUMBER:
OWNER: TEL,. NO: PLAN CHECK NUMBER: F BY: CODE:
JUA(}-MU Im _ (626) 292-1671- JOB NR-MER:
6121 CAMlaffIA AVE TRUNK PERMIT NUMBER:
TE24PLE CITY CA 91780 ROAD PERMIT NU BER: _ OF WORK
AFFADAVIT: NO CONNECT NEW GUEST HOUSE PUBLIC SEWER
WAIVER: NO
APPLICANT: TEL. NO: EASEt4F2PT: NO
KO, DAVID (626) 672-8768-
5559 EARLS STREET RECORD IIQSTRDMENT NBR: RECORD DATE: SPECIAL CONDITIONS:
BAN GABRSEI, CA 91776 HIGHWAY/STREET WIDENING:
STATE ENCROACHMENT PERMIT NUMBER:
CONTRACTOR: TEL. NO: FEES PAID APPROVALS DATE INSPECTOR SIGNATURE
TING LING KO (626) 622-8768-
5559 EARLE ST LSC. NO FEE DESCRIPTION: QUANTITY: UOM: AMOUNT: NEW RDUSE SEWER
SAN GABRIEL, CA 91776 671176-B
01 PERMIT ISSUANCE FEE 27.80 CONNECT ADDITIONAL
03 CONN TO PUBLIC SEWER 1.00 CON 47.00 BUILDING OR FORK
ARCHITECT OR ENG TEL. NO: TOTAL FEES 74.80
SEPTIC TANK, SEEPAGE PTT
LIC. NO: AND/OR DRAIN FIELD
DRYMELL
SEWER MAP BOOL: PAGE: ALTER, REPAIR, SEWER OR
SEWAGE DISPOSAL SYSTEM
DISCONNECT PLOD AND
AHANIJON ROUSE SEWER
AAlTFT>•1 SEPTIC TANKS _
SEEP. PTT CESSPOOL
ORAYVATER SYSTEM!
. • ADDITIONAL DATA ON FILE
REPORT ID: DPR-266 ROUTE TO 860508