HomeMy Public PortalAbout5128 FARAGO AVE_Sewer__ TEMPLE CITY
78A842D
BeAPPLICATION FOR PERMIT
CE90r H
COUNTY OF LOS ANGELES SEWER:: GE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS
JOHN A LAIE Count En meer
CMBASSAIT D GRIFFIN Supt of Building LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST
LEGAL
DESCRIPTION LOT NO OWNER
BLOCK TRACT MAI
RE
A
NO OF BLDG
SIZE OF LOT NOW ON LOT C TEL NO
USE OF
BUILDINGS DISTRICT NO P
GROUP MAP BK G PROCES D BY
I /
CONTRACTOR /J�
A CJ CONNECTION DATA
CITY NO ION DEPTH
STATE MANHOLEREFERENC
REGISTRATION NO O COUNTY
NO DESCRIPTION OF WORK FEE
J HOUSE SEWER CONNECTING TO
f, PUBLIC SEWER @ $3 00 TYPE OF COITNEtTION 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 1415 JOB NO
CONNECT ADDITIONAL BLDG OR
WORK TO HOUSE SEWER @ $1 00 TRUNK PERMIT NO ROAD PERMIT NO
ALTER REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
SEWER OR DISPOSAL SYSTEM @ $100 PERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PmmT $ 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE -,90 REIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSP tTOR S SIGNATURE
TO THE PUBLIC SEWER !
SIGNED THIS D �^ 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 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 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIR�LRO.LERT
OS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT THE LE R OF THE ABOVE
DESCRIBED RESIDEN BACKFILLSEPTIC TANKS ❑
SIGNATURE SE PIT(S) EICEJSPOOLS
OF PERMITTE
OF _ Ill TION ROBERT A WOOD
C� Y p Ggy SUPERVISING MECHANICAL ENGINEER
A.10g7 � � Qv17 o0 500
TEMPLE CITY
788842" .
CE80�,8 SB APPLICATION FOR PERMIT
7
COUNTY OF LOS ANGELES _ SEWER 4AGE DISPOSAL
1
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BU'LADORES G /
JOHN A LAM �a
BIE County Engeer
CAWATT D GRIFFIN Supt of Building LOCALIT
NEAREST
FOR APPLICANT TO FILL IN ceoss
LEGAL 1
DESCRIPTION LOT NO OWNER
BLOCK TRACT M
ADDR54
NO OF BLDGS `
SIZE OF LOT NOW ON LOT / TEL N0
USE OF
DI DISTRICT NO GROUP MAP PROCESSE BY
BUILDINGS
BK PG I
CONTRACTOR
ADD Es CONNECTION DATA
CITY L NO DEPTH
TATE AAWHOLE R FERE CE I PPE
REG SS AT N NO 9 COUNTY Qs
NO DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3 00 TYPE OF CONNECTIO LENGTH FR M
SEPTIC TANK SEEPAGE PIT OR Y C RB P L M L TOP
ITS 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
CONNECT ADDITIONAL BLDG OR TRUNK PERMIT NO ROAD PERMIT N
WORK TO HOUSE SEWER @ $1 00 i
ALTER
OR PAIRO R A SYSTEM HOUSE @ $1 0 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT $ CONNECTION CHARGE FEE
A=ORIZATIONI TOTAL FEE 0"0 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
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADDRESS SEPTIC TANK SEEP PIT(S)
AND/OR DRAINFIELD
1 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
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUf BY LOS ANGE TY AND STATE OF ABANDON CT PLUGHOUSE AND
CALIFORNIA OR T T 1 AM TH• OWN OF THE ABOVE
WER
DESCRIBED RESID IAL PROPE Y BACKFILL SEPTIC TANKS ❑
SIGNATURE Sfa PIT(S) Cl CES PO LS
OF PERMITTE
Or DATION ROBERT A W OD
m 0 CASH SUPERVISING MECHANICAL ENGINEER
L&8785 -
NOV 17 1 1 0 2500 M