HomeMy Public PortalAbout5461 ENCINITA AVE_Sewer__ TEMPLE CITY fiBOB --
c BOB a-aa D APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS
JOHN A. I.AMBIE, County En eer ..
C ATT D. GRIFFIN, Supt of Buildmg LOCALITY
NEAREST
FOR APPLICANT TO FILL IN caoss sT
LEGAL
DESCRIPTION LOT NO OWNER
Q
BLOCK TRACT MAIL
F 1A ADDRESS
SIZE OF LOT s'G NO OF BL
NOW ON LOT
CITY . TEL NOUSE OF
Ej
BUILDINGS DISTRICT NO GROU I MAP PROCESSED BY
/ BK sPG
CONTRACTOR
ADDRESS CONNECTION DATA
CITY TEL NO STATION DEPTH
STATE MANHOLE REFERENCE UPPER
REGISTRATION NO COUNTY LOWER
No I DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3 00 TYPE OF CONNECTION LENGTH FROM
SEPTIC TANK SEEPAGE PIT OR Y CURB P L M L TO P L
PITS AND/OR DRAINFIELD @ $3 00
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL @ $2 00
HOUSE SEWER CONNECTING TO P C NO
PRIVATE DISPOSAL SYSTEM @ $1 00 CO IMP NO JOB NO
COECTWORK TO HOUSEDDITISEWERBLDG OR @ $1 00 TRUNK PERMIT NO ROAD PERMIT NO
S 1 ABANDON HOUSE "00 OV STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL -
WASTE APPROVAL
CHARGES
OWNERS PERM $ 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE 1_>`1 V C/ REIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR S SIGNATURE
TO THE PUBLIC SEWER
SIGNED THIS DAY OF 19__ NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADDRESS SEPTIC TANK SEEP PIT(S)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWER OR /
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM /
All
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND ) // J
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER / �V l
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIAL PROPERTY BACKFILL SEPTIC TANKS ❑
SIGNATURE ' SEEP PIT(S) ❑ CESSPOOLSrl
OF PERMITTED
®° VALIDATIOI---� ROBERT A WOOD
B O :7
SUPERVISING MECHANICAL ENGINEER
L�t�o 8 1 9 4 DEC 10 1 o D 5.00, `