HomeMy Public PortalAbout5023 FARAGO AVE_Sewer__ TEMPLE CITY
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8 8B APPLICATION FOR PERMIT 1
C6808
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING vt
ADDRESS e
_
JOHN A LAMIE Count
F E eer
CASSATT D GRIFFIN Sup t ofTuild-g LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST
LEGAL
DESCRIPTION LOT NO 3 OWNER
BLOCK TRACT MAIL
ADDRESS
NO OF BLDGS
SIZE OF LOT NOW ON LOT CITY TEL NO
USEOF
DI !EN
DISTRICT NO GROUP MAP PROCES D BYBUILDINGSK PGCONTRACTOR OADDRESS S��_ C CTION DATA
CITY T �4 � �&O CB ON DEPTH
STATE MANHOLE REFERENCEREGISTRATION NO COUNTY a LOWENO DESCRIPTIO OF WOF �rPUBLIC SEWERCONNECTING @ $3 00 ��+�/SEPTIC TANK SEEPAGE PIT TYPE OF CONNECTION LENGPITS AND/OR DRAINFIELD@ S3 00 Y CURB P L ML TOPL
OVERFLOW SEEPAGE PIT DRD
EXTN CESSPOOL DRYWELL@ S2 00
HOUSE SEWER CONNECTING P C NO
PRIVATE DISPOSAL SYSTEM@ V 00 CO IMP NO �—� JOB NO
WORK TO ADDITIONAL BLDG
OR @ SI 00 TRUNK PERMIT NO ROAD PERMIT NO
SEWER 0 EPAIROR L SYNDON HOUSE @ $I 00 STATE ENCROACHMENT
PERMIT NO
W INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNER S PERMIT a CONNECTION CHARGE FEE
UTHOMATION TOTAL FEE REIMBURSEMENT FEE
I 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 U{}
OWNER OR ? CONNECT ADDITIONAL
OWNERS AGENT /', BUILDING OR WORK
ADDRESS SEPTICTANK SEEP PIT(S)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL ❑ ( 1
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT 1 A THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIA P XIPERTY BACKFILL SEPTIC TANKS ❑
SIGNATURE SE§& PIT(S) ❑ CESSPOOLS ❑
OF PERMITTE 0
VALIDATION ROBERT A WOOD
CK. M 0 CASM SUPERVISING MECHANICAL ENGINEER
L :a0 6 70 )IN 3 D 2500
f' TEMPLE CITY
7611,14
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CE808 APPLICATION FOR PERMIT
eeoe a as COUNTY OF LOS ANGELES
SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING
BUILDING AND SAFETY DMSION ADDRESS i4 2D A t
ISTNtiCnATDcWITnspo famg LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST
LEGAL
DESCRIPTION LOT NO OWNER
L
OCK TRACT MAIL
ADDRESS
NO OF BLDGS
E OF LOT NOW ON LOT CITY TEL NO
USE OF
BUILDINGS DISTRICT NO GROUP MAP PROCESSED BY
,./� K PG
CONTRACTOR _5-, O a
ADDRESS 13
CONNECTION DATA
CITY TEL NO O SIWION DEPTH
STATE
REGISTRATION NO d B COUNTY MANHOLE REFERENC rLOW—ERl-
NQ I LOW-
ERI-NDESCRIPTION'OF WORK FEE -`!�
HOUSE SEWER CONNECTING TO G!1!
PUBLIC SEWER @ $300 P
SEPTIC TANK SEEPAGE PIT OR Y TYPE OF CURB
CONNECTIONP L LEL NGT TO P L RCTM �S
PITS AND/OR DRAINFIELD @ S32-0-
OVERFLOW
800OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL @ $200
HOUSE SEWER CONNECTING TO �� P C NO
PRIVATE DISPOSAL SYSTEM @ S1 00 CO IMP NO JOB NO
WORK TOTHOUSEISEWEBLDG OR @ SI 00 TRUNK PERMIT NO ROAD PERMIT NO
SEWER OR PAIROR ABANDON HOUSE @ $I 00 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNER S PST S 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE _r /�V REIMBURSEMENT FEE
I 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 • 5')
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT_ L BUILDING OR WORK
ADDRESS SEPTIC TANK SEEP PIT(S)
AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I 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
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE
LO
SCRIBED RESIDENTI PROPERTY BACKFILLSEPTIC TKS ❑
NATURE S P PITS CESSANPOOLSF PERMITTE �66
OF VALIDATION ROBERT A WOOD
CK Y 0 CASR SUPERVISING MECHANICAL ENGINEER
LpV00 o 6 60 „nJ 3 1 0 0 500