HomeMy Public PortalAbout4541 CLOVERLY AVE_Sewer__ TEMPLE CITY
76A 6 2/70 APPLICATION FO® PERMIT
76A 642D APPLICATION E® E a
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING ))� /1 TT
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS �y 41 N. Cloverl Ave.,
COLEMAN W. JENKINS. SUPT. OF BUILDING
LOCALITY IPP y 1 P I
7ESCRiPTION
OR APPLICANT TO FILL IN NEAREST
(PRINT OR TYPE ONLY) cao55 57T S�+P 1
LEGAL
[BLO
'T'
LOT NO. OWNER �J o E o Blalock
MAIL J4 541 T\ Cloverly Ave.
TRACT ADDRESS may' 1NO. OF BLDGS. (tf��'1QQ NOW ON LOT CITYTemnle Cit TEL. NO. 444-2872
USE OF
BUILDINGS DIST RiI�CT NO. GROUP f.LA55 MAP PROCESSED BY
PS
CONTRACTOR Square Deal Sewer Service '" B� ,r
ADDRESS 29,33 Maxson Rd. CONNECTION DATA
CITY El Monte TEL. NO. 4.44-2020 �� STATION // (y DEPTH -
LICENSE ND:. 128870 CLAS17
STAT LIC
S C-Lf2 �' MANHOLE REFERENCE �{ e /
C/ LOWER
NO. .DESCRIPTION OF WORK FEE TYPE OF CO TION LENGTH F OM
HOUSE SEWER CONNECTING TO 00 Y. CURB P.L. M.L.TO P L.
1 PUBLIC SEWER @ S5.00 P.C.NO.
SEPTIC TANK.SEEPAGE PIT OR CO.IMP. NO. JOB NO.
PITS AN OR DRAINFIELD $10.00
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM @ $3.00 eo g.
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT I WAIVER EASEMENT RECORD. INSTR. NO, D TE O
WORK TO HOUSE SEWER @ S3.00 (�
OVERFLOW SEEPAGE PIT.DRAINFIELD
EXTN..CESSPOOL.DRYWELL.MANHOLE @ SS.00 HWY. OR ST.WIDENING
ALTER.REPAIR OR ABANDON HOUSE V
SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHMENT
PERMIT NO. Lu
INDUSTRIAL N
WASTE APPROVALz
CHARGES
OVINER'S PERMIT $ 00
AUTHORIZATIONAUTHORIZATION1 TOTAL FEE 1 O OO CONNECTION CHARGE FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- a REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER- APPROVALS DATE I N SPECTOWSSIGN ATURE
k
ED THIS DAY OF 19_ 41
R OR NEW HOUSE SEWER
TIC T
RS AGENT
CONNECT ADDITIONAL
SS BUILDING OR WORK
SEPTIC TANK.SEEP,PIT(S)
REBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND�OR DRAINFIELD
TATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
ALL COUNTYORDINANCES AND STATE LAWS REGULATING
ING AND SEWERS. CESSPOOL ❑ DRYWELLREBY CERTIFY THAT I AM PROPERLY REGISTERED AND�OR ALTER,REPAIR.SEWER OR
SED AS REQUIREDBY LOS ANGLES COUNTY AND STATE OF SEWAGE DIS POSAL SYSTEM
ORNIA OR THAT 1 AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
E IN, THE ABOVE DESCRIBED RESIDENTIAL ROP RTV. ABANDON HOUSE SEWER
TURE /,,�{�PERMITTEE"" 9 �'�`�" SANKS
EEP.BACKFPIT(SILL EP❑ CESSPOOLS
` 111
V LIDATION ACK R. ALLEN
OSUPERVISING MECHANICAL ENGINEER
CK. O. CASH
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