HomeMy Public PortalAbout10816 DAINES DR_Sewer__ IM4PLE CITY
CE90610-63 APPLICATION FOR PERMIT
T6A642D
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOIN A. LAMBIE, County Engineer ADDRESS 10816 C
WILLIAM A. JENSEN, Sup't of Building LOCALITY Temple City
NEAREST
FOR APPLICANT TO FILL IN GROSS ST. Mc C011och
`EGALl g�l:-(�`d -g'1' 6 Robert Blake
OEBCRIPTION LOT N0. / OWNER
MAIL
BLOCK TRACT D .
,t YA �(��V ADDRESS10816 F. -1 n G v
o. OF L
D-
S
W N
SIZE OF LOT NOOLOT 1 CITY Temple Cit,11TEL NO.
USE.OFRes • DISTRICT NO, MAP PROCESSED BY
BUILDINGS
BK PG
CONTRACTOR Square Deal Sewer Service J (J � GROUP — It9
ADDRESS 293 TJ 2 xs Or) Rd . CONNECTION DATA
STATION :171"
DEPTH
CITY nni- TEL. NO, r _'J lJ ,i (J'�/
ElSTATE MANHOLE REFERENCE
G 'fes / / UP
REON NO. 128870 [:1COUNTY y [411,oyf /, TOIPER
P
NO. DISTRATIESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM /
1 PURL
=CONNECTING
ERCONNECTING TO @ $5.00 OO Y CURB F,L. M.L.TO P.L. L1
SEPTIC TANK,SEEPAGE PIT OR POR NO.- 30 Oyp( 1 O
PITS AND/OR GRAINFIELD @ S10,00 CO.IMP.NO, 5 JOB NO, l ^"
V
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM @ 53.00 R'
CONN OS EAE BLDG.OR AFFIDAVIT plvp5[MCM flECOftG.IN$TR.NO. DATE O
WORKK ToCT HOUSE
SEWER @ 53.00 v
OVERFLOW SEEPAGE PIT,GRAINFIELD W
EXTN.,CESSPOOL,DRYWELL,MANHOLE Ib 55.00 D_
ALTER.REPAIR O R ABANDON HOUSE HWY.OR ST,WIDENING Z
SEWER OR DISPOSAL SYSTEM @ $3,00 STATE ENCROACHMENT
PERMIT NO,
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERSPERMIT s 21 00
ALTTHOPUATION TOTAL FEE 71 OO ONN ECTION CHARGE FEE
'I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS GATE INSPECTOR'S SIGNATURE
TO THE PUBLIC FEWER.
SIGNED THIS DAY OF 19_
OWNEROR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK 1
SEPTIC TANK,SEEP.PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATI
PLUMBING AND SEWERS. CESSPOOL ❑NG
DRYWELL El
IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER.REPAIR.SEWER OR
CALIFORNIAAS REQUIRED BY LOS AAL .N.1 AND
STATE OF SEWAGEDISPOSAL
PLUG
SYSTEM
CALIFORNOR THAT AM THE LEGAL OWNS F. AND INTEND TO SEWAGNECT PLUG AND
RESIDE IN, THE ABOVEp BOVE NIBED F N A F.PERTY' ABANDON HOUSE SEWER
SIGNATURE F'
OF PERMITTEE ` BACKFILL SEPTIC TANKS ❑ ^ ♦
SEEP, PIT(B) ❑ CESSPOOLS ��IC� s �_ �I �l�1
OVALIDATION ROBERT WOOLN
SUPERVISING MECHANICAL ENGINEER
CK. M.O. CASH
_tiro 7 a APR 1 1 o A 7.00-
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