HomeMy Public PortalAbout9059 EMPEROR AVE_Sewer__ TEMPLE CITY
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5.65
6A642 D APPLICATION FOR PERMIT
7 6A 64
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A LAMBIE, County H nglneer ADDRESS E. Em eror
COLEMAN W JENKINS,Sup't of Ruildmg
LOCALITY Temple
S
CFA..T Rosemead Blvd.
FOR APPLICANT TO FILL IN /( + y� D
DESCRLE IPTION LOT NO (/vAL / O OWNER llillion Bade
MAIL
BLOCK TRACT ADDRESS 90
i
rchcroft
NO OF BLDGS Y�
SIZE OF LOT NOW ON LOT CITY q TEL NO 6
USE OF DISTRICT NO GROUP MAP PROCESSED BY
BUILDINGS Q
/./ BK PG
CONTRACTORJ f
ADDRESS 2933 Maxson Rd. 74, — CONNECTIO DATA
CITY El Monte TEL NO -2020 STATION 74 DEPTH -�
LICENSE 1288 0 CLASSLICENSE C-42-42 MANHOLE REFERENCE s-� U
NOW
0o L WER
NO DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y CURB P L M L TO P L
PUBLIC SEWER @ $ 5 00
P DANK, SEEPAGEJ
T R O NO
PITS AND/OR DRAINFIELD C $1 0 00 CO IMP NO OB NO 0
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO U
PRIVATE DISPOSAL SYSTEM @ $ 3 00
CONNECT ADDITIONAL BLDG OR AFFIDAVIT WAIVEN EASEMENT RECORD INSTR NO DATE
WORK TO HOUSE SEWER C= $ 3 00 O
'ALTER, R5PAIR OR ABANDON HOUSE r
SEWER OR DISPOSAL SYSTFM C $ 3 00 LLVI
HWY OR ST WIDENING-1 LOW
a
EXTN CESSPOOL, MANHOLE @ $ 5 00 STATE ENCROACHMENT h
PERCOLATION TEST 9 $ 5 OG PERMIT NO z
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT S z 00
AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEE`
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER APPROVALS DATE INSPEC 5 SIGNATURE
SIGNED THIS DAY OF 19_ c
OWNER OR NEW HOUSE SEWER /G"A
OWNERS AGENT
CONNECTADDITIONAL
ADDRESS
BUILDING OR WORK
SEPTIC TANK SEEP PIT(S)
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
LRESE
TE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
L COUNTY ORDINANCES AND STATE LAWS REGULATING
G AND SEWERS CESSPOOL ❑ DRYWELL ❑
BY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
IA OR THAT I AM THE LEGAL OWN OF AND INTEND TO DISCONNECT PLUG AND
N THE ABOVE DESCRIBED RESIDE IAL OPERTY gBANDON HOUSE SEWER
RE BACKFILL SEPTIC TANKS ❑MITTEE 11 SEEP PIT(S) ❑ CESSPOOLS ❑
ALIDATION
f-1
M O CASH
LAL�, 0 3 7 5`03 ,,UG30 1 0 D 7.00 ~
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7C E808
6A64I20 0-63 APPLICATION FOR PERMI
A64
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION FNEAREST
JOHN A LAMBIE, County Engineer 0 0 #X/E
WILLIAM A JENSEN, Sup t of Building 7 1
FOR APPLICANT TO FILL IN 7 o S
LEGAL `
DESCRIPTION LOT NO Q L9, AP T CO OWNER G (/�
' MAIL /
BLOCK TRACT 1 ! ADDRESS 0 f�EX
NO OF SLOGS y
SIZE 7,f OF LOT NOW ON LOT CITY 1RG/ 1,/7 TEL NO
USE OF f� DISTRICT NO GROUP MAP PROCESSED BY
BUILDINGS
BK PG
CONTRACTOR // a R j 0 L !� - _ e
ADDRESS (�(� ,�y p�✓ ( CONNECTION DATA
CITY EC M Q/`- .(� TEL NO STATION DEPTH
STATE MANHOLE R FERENCE UPPER
REGISTRATION NO COUNTY LO
NO DESCRIPTION OF WORK FEE TYPE OF'V,.
N NECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y URB P L M L TOP }
PUBLIC SEWER @ Ss Do
PC N9 O.
SEPTIC TANK SEEPAGE PIT OR
PITS AND/'CR DRAINFIELD @ S1000 CO IMP NO 9'NO O
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO V
PRIVATE DISPOSAL SYSTEM @ S300 cm
CONNECT ADDITIONAL BLDG OR AFFIDAVIT I WAIYEY E [NT RE RD INSTR NO DATE Q
WORK TO HOUSE SEWER @ $300
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL MANHOLE @ SS OO 141
/ Afrtl9rAlflEIR ABANDON HOUSE HWY ST WIDENING d
/ 90tlGaO�DISPO SAL SYSTEM $300 H
STATE ENCROACHMENT Z
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT S z 00 CHARGES
AUTHORIZATION TOTAL FEE CONNECTION 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
TO THE PUBLIC SEW R DATE INSPECTOR 5 SIGNATURE
SIGNED THIS t DAY OF �I 19AC—z
OWNEROR `� NEW HOUSE SEWER
OWNERS AGENT /f]Lcr �LLL,r- '� +/ CONNECT ADDITIONAL
ADDRESS �l.�d�O BUILDING OR WORK
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION SEPTIC TANK SEEP PIT(5)
AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF AND INTEND TO DISCONNECT PLUG AND
RESIDE IN THE ABOVE DESCRIBED RESIDENTIAL PROPERTY ABANDON HOUSE SEWER
SIGNATURE �iL/iJ/T' '-' i BACKFILL SEPTIC TANKS ❑ L'
OF PERMITTEE j�/ SEEP PIT(S) ❑ CESSPOOLS ❑,
VALIDATION ROBERT A WOOD
CK M O CASH
\(� SUPERVISING MECHANICAL ENGINEER
LA,o 8 0 9 5 APR 18 1 0 D 5.00-