HomeMy Public PortalAbout6348 GOLDEN WEST AVE_Sewer__ • '}w TEMPLE CITY
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7EA APPLICATION FOR PERMIT
042.D42D
COUNTY OF Lob ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER 1,
BUILDING AND SAFETY DIVISION w
ADol�ew 6348 N. Golden West
JOHN A. LAMBIE, CouNTY EwamEER
COLEMAN W. JENKINS. SUPT. of BUILDING LOCALIT' Temple Cit
NEAREST
APPLICANT TO FILL IN CRO" ST, Longden Ave.
(PRINT OR TYPE ONLY)
DESCRIPTION LOT NO. owNER Richard Bowen
MAIL
BLOCK TRACT 2P, 3 ADDRESS
SIZE OR LOT NOWOONB L,-OTB 1 CITY ArcaddA TIEL. NO.
UlGK OF
BUILDINGS Res. DISTRICTNO. GROUP CLASS MPARPROC 1pE 5Y
. PS
aoNTAcroR �0 f: `
ADDRESS 2 MaxB n Rd. CONNECnON DATA
CITY El Monte TEL_ NO. -2020 STATION ' DEPTH
(�
UPPER
LICENSE NO. 1288?0 LICATE MANHOLESS C-42 MANHOLE REFERENCE m-11.
No. I DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTHM
HOUSC
E SWZR CONNECTING TO Y. cu RE P.L M.L.TOT
PUBLIC S.EW[R 0 7-
NO.
EPT'
C TANK.• GE P 011 JOB NO.
PITS AND/oR DRAINFI[LD 0 x10.00 CO.SMR.NO.
HOUSE SEWER CONNECTING TO THUNK PE11M1T NO. ROAD PERMIT NO. CL
PRIVATE DISPOSAL SYSTEM 0 $3.00 O
CONNECT ADDITIONAL aLDd.6m AFFIDAVIT I V a 'wulR RECORD.INSTR.NO. DATE V
WORK TO FIOUSE SEWER 0 $2.00
OVERFLOW SILEPAGE PIT,DRAINFI[LD OG
E)LTH..CESSPOOLDRYWELL.MANHOLE 0 95.00 O
ALt",
RVAIR OR ABA DO HWY.OR ST.WIDENING
SEWER OR DISPOSAL SYSTEM 3.00 STAT[ENCROACHMENT Ll(LJ,
PERMIT NO.
INDUSTRIAL U`)
WAJT[APPROVAL - Z
CHARGES
OVVNE:ErS PE bffr s 00
AV HORIZATION TOTAL FEE ON CONNECTION CHARGE FILE _
I HAVE AT THISDAT[ A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED LXI<TINQ ING
DWELL
TO THE PUBLIC SEWER. APPROVALS DATE I ECTOR' S NATURE
SIGNED THIS DAY OF 1G_
OWNER OR NEW HOUR[SEWER
OWNERS AGENT
CONNECT ADDITIONAL
BUILD[NO OR WORK
ADDRES■
SEPTIC TAH K.SEEP.PIT(S)
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THI■ APPLICATION AND/OR DRAINFI[LD
AND STAT[ THAT THEABOVE If CORRZCT AND AGR[[ TO COMPLY
WrTH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMSING AND NEWS". C:X"POOL ❑ DRYWZLL ❑
I HERESY CERTIFY THAT I AM PROPERLY REGIBTERI D AND/OR ALTTJI.RVAIR.SEWER OR
LICENSED AS REQUIRED ■Y LOS ANGLES COU AND STAT[ OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL ON MER O AHD INTEND TO DISCONNECT PLUG AND
RAID[ IN, THE ABOVE D I■ II[1ID ENTIAL ROP ABANDON NOUS[SEW[R
SIGNATURE SAC KFILL
SuP'[�C TANKS ❑
OF P[R MTTTQ SEEP.PIT({) LJ CESSPOOLS
AlMATION JACK R. ALLHN
SUPERVISING MECHANICAL ENGINEER
CK. M.O. CASH
1 3 3 0z- J& 9 1�) D 1 0.00- Q