HomeMy Public PortalAbout6261 GOLDEN WEST AVE_Sewer__ DEeoe a-ee
7 5A e.tz D APPLICAT10 FOR PERM {�
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COUNTY OF IAS ANGET, SEWER—SEWAGE DISPOSAL
D8PARTMENT OF COUNTY ENGINEER
BUMDING AND SAFETY DrMION eu1LDINa
JOHN A. LAIIBIE, CountT Engineer ADDRESS
COLEMAN W. JENCINS,Sup t. of Bnfldlrts
LOCALITY
NEAREST
'ALFOR APPLICANT "TO FILL IN CRDes ST.
DESCRIPTION LOT NO. OWKER t ��
WAIL +
■LOCK TRACT ADDRUS /1�
O► ELDOG. +�j
SIZE OF LOT O LOT CITY TI O.
USE OF DI"ICT NO. GROUP MAP. PROCWEb BY
BUILDINGS
OK 1-0
wry / J
CONTRACTORT) aid
P a�
A 5jajR L" Q CONNE CM DAr
STATION , 3 DEPTH
LICE
N0. SE Q / CLA//' F -$C�I.O'SC MANHOLE R[M[R[NC[ U
No. DESCRIPTION OF WORK FEE TYPE ofco ION LENGTH FRow
HOUSE FEWER CONN[(:T ENG TO Y. R■ P.L_ Y.L.TO F.L
PUBLIC SEWER • S 5.00
PIT OR F.C.NO.
PIT/ AND/'OR'DRAINFIELD • =10.00 CO,IMF.NO. JOS No.
HOUSE SEW ER CONNECTING TO TRUNK PERMIT No. ROAD P RM1T NO �I
PR LVATE DI/POSAL IYfTEM • j 9,06 d(
4. R AFFIDAVIT I WATgl EM"Kiff RECORD.INSTR.NO. DATI
WORK TO HOUSE SEWER 0 $ 9.00
'ALTER, REPAIR QR ABANDON HOUNE
SEWER OR DISPOSAL SYSTEM 0 j 9.00
HWY.OR ST.WIDENING Md.
EXTN.,CES/POOL, MANHOLE 0 j 5.00 STATE ENCROACHMENT
PERCOLATION TEST • $ 5.00 PERMIT NO.
INDUSTRIAL
WAST[APPROVAL
OWNER'S PERMIT s i 00 CHARGES
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE
REIMBURSEMENT FEE
'1 HAVE AT THIS DAT[ A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE D[SCRISED pS1iTIN0 DWELLING
TO THE PUBLIC S � T R gOVADAT[ INSPECTOR' GNATUR[
SIGNED Til DAY OF 1
OWNER OR -7�1 ' NEW HOUSE SEWER
OWNERS AO[NT CONNECT ADDITIONAL
ADDRESS r. Ll BUILDING OR WORK
SEPTIC TANK.SEP,PIT(9)
I HEREBY ACKNOWLEDGE THAT I HAVE R[Ab THIS AFPLIGATION AND/OR DRAT NFIEL.D
AND STAT[ THAT THE ABOVE IS CORRBCT AND AGR[[ TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE L�,WS REGULATING
PLU Mo ING AND SIWERS. Is
ESSPOOL ❑ DRY [LL ❑
I HERBY CERTIFY THAT I AM PROPERLY REGISTERED AND/ORLTER.R[PAI R.SEWER OR
LICENSED AS REQUIRED BY LOS LX8 COUNTY AND STATE OFEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE A OWNER OF,AND INTEND TOISCONNECT PLUG AND
RESIDE IN, THE ABOVE DESCRI■ ID[NTIAL PROPERTY.
ABANDON HOGS[SEWER
SIGNATURE ❑
OF PERMITTEE ACKFILL SI( IC TANKS
[EP,PrT I -- OLS
VALIDA
C,
Y.O. CATH
Lko 0252 Am231 0 9 7.00-
,
T t
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 SEWER PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS SE 0508 0003010001
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
LEGAL ID: SEWER SEPTIC: X BUILDING
ON FILE EXIST OCC GRP: 6261 GOLDEN WEST:AV
BLDGS. NOW ON LOT: TEMP CA 917801705
CONNECTION TYPE: NEAREST CROSS STREET: LONGDEN
5385-021-008 ORIGINATION: THOMAS PAGE: 597 GRID: A2 LOCALITY: TEMPLE CITY
LENGTH ML TO PL: STATION: DEPTH:
MANHOLE REFERENCE: UPPER/LONER: ISS06 ON: .
COUNTY IMPROVEMENT NUMBER: 03/ (00,- UT O8 8/00 .
OWNER: PLAN CHECK NUMBER: FINAL BAT Y: CODE:
SOLISMARIA (626) 286-9349- JOB NLMBER: UPIRED
6261 GOLDEN HEST AV TRUNK PERMIT NUMBER: r
TEMP 917801705 ROAD PERMIT NU13ER: �DESCRIPII� Or WORK
AFFADAVIT: NO REPL,ti10EMENT OF wY" CLAY MAIN LINE
WAIVER: NO
APPLICANT: TEL. NO: EASEMENT: NO
RESCUE ROOTER (626) 333-1217-
681 SAN BERNARDINO RECORD INSTRUMENT NB RECORD DATE: SPECIAL CONDITIONS:
COVIIiA, CA HIGHWAY/STRE
STATE ENVUR
N
CONTRACTOR,. TEL. NO: - APPROVALS WE— INSPECTOR SIGWATURr--
RESCUE ROOTER (626) 965-1569- , 0 I
681 E. SAN BERNARDINO RD LIC. NO E TION: OUANTIT AMOUll1T: NEW rDUSE SEWER _ D
COVINA, CA 91723 744542 B
IT F 27.75 CONNECT ADDITIWI
5 LT HOUSE 1.00 EA 30.45 BUI ' ING OR WORK
ARCHITECT OR ENGINEER- TEL. NO: I TAL F ES 58.2SEPTIC 0
LIC. N 111111 AND/IOR DRAIN FIELD
SEWER MAP BOOK: PAGE: REPAIR SEWER
II tl�rfi��� 111J11U ®�IKC SEWG� DISPOSILL SYSTEM
AND
DISqONNECT PLUG
ABAM
DON HOUSE SEWER
Q ❑ SEEP.'P IT CESSPOOL
.o4b'jc Ser at�� b
f vice Th
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' ADDITIONAL DATA ON FILE
REPORT ID: DPR266 ROUTE TO BS0508
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