HomeMy Public PortalAbout10766 FAIRVIEW AVE_Sewer__ CE808 3-61
76A642D APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A, LAMBIE County Engineer ADDRESS
WILLIAM A JENSEN Supt of Building_ LOCALITY TEMPLE CITY CALIF.
F"NEAREST GRANT) AVENUE
FOR APPLICANT TO FILL IN FILL , ST
LEGAL
( DESCRIPTION LOT NO OWNER RICHARD SCHOTT
BLOCK TRACT Q �_ MAIL
ADDRESS /�
NO OFBLDGS /�
SIZE OF LOT NOW ON LOT CITY yEL NO
.PL 12268
USEOF
DI DISTRICT NO GRO MAP PG PROCESSED BY
BUILDINGS
CONTACTOR
A. S.TOMICH
ADDRESS 5922PTO ENCINITA CONNEATA
CITY TEMPLE CITY TEL NO AT 6-389 STATION � L{ CTIox DEPTH ,STATE _
REGISTRATION NO COUNTY MANHOLE REFERENCE �0 f UP
No I DESCRIPTION OF WORK FEE �q_/'�
PUBLICSSEWERCONNECTING TO @ISE 00 - V'''
SEPTIC TANK SEEPAGE PIT OR i3 0 TYPE OF CONNEC LENGTH FROM
PITS AND/OR DRAINFIELD @ S8 00 Y CURB P L M L TO P L
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL @ S2 00 d
i HOUSE SEWER CONNECTING TO �JfJ08C NO NO O
PRIVATE DISPOSAL SYSTEM @ S1 00 CO IMP NO V
WORK TO ADDITIONAL
EBLDG OR @ Sf 00 TRUNK PERMIT NO ROAD PERMIT NO
d'
SEWER OR DISPOSAL SYSTEM HOUSE @ $1 00 STATE ENCROACHMENT Q
PERMIT NO
INDUSTRIAL
WASTE APPROVAL d
N
CHARGES Z
OWNER'S PERMIT $ 2 00 CONNECTION CHARGE FEE +
AUTHORIZATION I TOTAL FEE Z REIMBURSEMENT FEE
TRTHIS
ONNECT THE ABOVE DESCRIBEDSCRIBED EXWITH THE IST NG DWELLIING EIN NAMED CON- APPROVALS
ACTOR TO CDATE INSPECTOR S SIGNATURE
TO THE PUBLIC SEW ,^�
SIGNED THI D V OR ``19S.JL NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL s `'
OWNERS A _ BUILDING OR WORK
ADDRESS — 7` SEPTIC TANK SEEP PIT(S)
AND/OR DRAINFIELD
LCDESCRIBE
HER ACKNOWLEDGE THAT t HAVE READ THIS APPLICATION
TE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL
LL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWEROR
NG AND SEWERS SEWAGE DISPOSAL SYSTEM
EBY CERTIFY THAT I AM PROPERLY R TERED AND/OR DISCONNECT PLUG AND
D AS REQUIRED BY LOS ANGELES CO TY AND STAT OF ABANDON HOUSE SEWER
NIA OR THAT THE LEGAL NER OF THED RESIDENT P PERTY ��BOIE
BACKFILLSEPTIC
TANKS ❑
RE- SEEP PITS ❑ CESSPOOLS
MITTE
VALIDATION ROBERT A WOOD
OK. Y 0 CuH SUPERVISING MECHANICAL ENGINEER
IiO,5 5JUL 2 1 0 D 7JOON e