HomeMy Public PortalAbout6220 GOLDEN WEST AVE_Sewer__ TEMPLE CITY
CE608 8-894 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUII.DING AND SAFETY DIVISION ADDRNG
ESS �Z20 /� C7Ol��s� WCf
JOHN A. LAMBIE, County Engineer
CASSAIT D. GRIFFIN, Supt of Building LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL /> OWNER
DESCRIPTION LOT NO. l/
BLOCK 6 ' TRACT Ile ADDRESS
ADDRESS 5�@�e
NO OF BLDGS.
SIZE OF LOT E7 JrD NOW ON LOT CITY TEL NO 7_fO�•
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USE OF
DI DISTRICT NO. GROUP MAP PR CESSED BY
BUILDINGS GL�lS ^� BK PG
CONTRACTOR Q I / 7 2 ^ ��
ADDRESS CONNECTION DATA
CITY TEL.NO. STATION -f-� Q DEPTH
STATE MANHOLE REFERENCE UPPER
REGISTRATION NO. COUNTY LOWER
NO. DESCRIPTION OF WORK FEE s IQ d J
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.N0. +
PRIVATE DISPOSAL SYSTEM @ $1 00 CO.IMP N0. JOB NO.
CONNECT ADDITIONAL BLDG.OR
WTQ.HOUSE SEWER @ $1 00' TRUNK PERMIT NO. ROAD PERMIT N0.
'
OR DISPOS L SYSTDEM HOUSE @ $1 00 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL -
WASTE APPROVAL
CHARGES
OWNERS PERMIT S 21 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE 6-b REIMBURSEMENT FEE
DATE A CONTRACT WITH THE HEREINAMkD,CN-
TRACTOR TO CIONNECT 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 I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRY-WELL ❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT 1 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
DESCRIBED RESIDENTIAL PROPERTY BACKFILLSEPTIC TANKS ❑
SIGNATURE SEEP PIT(S) ❑ CESSPOOLS
OF PERMITTEE
®� f` AJIDATION ROBERT A. WOOD
CIL to o. CASH SUPERVISING MECHANICAL ENGINEER
L �'I..:i O O W D 0 E