HomeMy Public PortalAbout10124 GREEN ST_Sewer__ T1 1IPLE CITY
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76A645-65
APPLICATION FOR PERMIT {�
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COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION
F
DINGJOHN A.LAMBIE, County Engineer ESS 1012 -26-28 E. Green St.
COLEMAN W. JENKINS,Sup't. of Building LiTY Temple CityESTFOR APPLICANT TO FILL IN S ST. Raidwin Ave,
LEGAL �+
DESCRIPTION LOT NO. Por. of 45 OWNER T.nstgr Bell
BLOCK TRACTE. J. Baldwin Add* rt MAIL
1 ADDRESS Baldwin Ave
NO. OF SLOGS.
SIZE OF LOT NOW ON LOT 3 CITY Arcadia TEL. NO.
USE OF
BUILDINGS DISTRICT,NpO�. GROUP MAP PROCESSED BY
IBK PG
CONTRACTOR Square Deal Sewer Service ^p C1 � � --�3� (Z
ADDRESS 2933 Maxs on Rd. CONNECTION DATA
CITY El Monte TEL. NO. t�.44-2020 STATION ���`� -74- df DEPTH
LICENSE LICENSE UPPER
C
NO. 128870 LASS C� 2 MANHOLE REFERENCE t
NO. DESCRIPTION OF WORK FEETYPE OF CONNECTION_-----.,, LENGTH FRO
1 HOUSPUBLEC E WER CONNECTING TO $ 5.00 Y. CU
PTI TSEEPAGE PIT OR P.C.NO.
RB P.L. M.L.TO P.L.
00 d 5 ANK, :y SMP NO JOB NO.
PITS AND�DR DRAINFIELD C $10.00 O
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. V
PRIVATE DISPOSAL SYSTEM C $ 3.00
2 CONNECT ADDITIONAL BLDG. OR 00 AFFIDA wAIYER EASEMENT RECORD.I TR O. DATE 0
WORK TO HOUSE SEWER C $ 3.00 r/y /
RE OR AB ND N HOUSE `
SEWER OR DISPOSAL SYSTEM $ 3.00 YYYJJJ
UV'R'LOWSEEPA15E F'1, UKAINPItLU HWY. OR ST.WIDENING d
EXTN.,CESS POOL, MANHOLE $ 5.00 STATE ENCROACHMENT Z
PERCOLATION TEST $ 5.00 PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT $ 21 00 CHARGES
AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEE
-I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS
TO THE PUBLIC SEWER, DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT
CONNECT ADDITIONAL
ADDRESS
BUILDING OR WORK
SEPTIC TANK,SEEP,PITS)
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL [I DRYWELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABOVE DESCRIBED RESIDE IAL PROPERTY. ABANDON HOUSE SEWER
SIGNATUREB
OF PERMITTEE BACKFILL SEPTIC TANKS E] �
SEEP,PIT(S) ❑ CESSPOOL J
ALIDATION
CK. M.O. CASH
�r �o LC 16 1 0 1 3.0
D
5IN E-663 11.55
APPLICATION FOR PERMIT 1
8 g E•8
DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL
Department of County Engineer
County of LOS Angeles BUILDING 2
JOHN A. LAMBIE. COUNTY ENGINEER ADDRESS
® CASSATT D. GRIFFIN, SUPT OF BUILDING LOCALITY
FOR APPLICANT O FILL IN CROSS ST.
LEGAL S OWNER
DESCRIPTION LOT NO. i�Y i
S 2 MAIL
BLOCK TRACT� � ADDRESS �
— .NO. OF BLDGS. CITY TEL, NO,
SIZE OF LOT NOW ON LOT
USE OF DISTRICT GR
.i I MAP
BUILDINGS
BK PG
CONTRACTOR
ADDRESS , - CONNECTION DATA
STATION DEPTH
C TY EL. NO. �j
MANHOLE REFE CE UPPER
t=ATE LOWER
REGISTRATION NO. �f "?/ ❑ COUNTY
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO TYPE OF CONNECT N LENGTH FROM
PUBLIC SEWER @ $3.50 Y. CURB .L. M.L.TO P.L.
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ $3.00
r OS..Sr�EErn---• -'�,.;.+,HF+SLD C. NO.
6N•f•t-,CESSPOOL,DWMiMEtt;ikhN•F}6ki @ $2.00 �✓� CO. IMP. NO. B NO.
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM @ $1.00 �® TRUNK PERMIT 0. ROA ERMIT N0. _
CONNECT ADDITIONAL BLDG.OR STATE ENCROACHMENT
WORK TO HOUSE SEWER @ $1.00 PERMIT NO.
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM @ $1.00 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT $ 1 00
REIMBURSEMENT FEE
AUTHORIZATION TOTAL FEE
449 APPROVALS DATE INSPECTOR'S SIGNATURE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON.
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. - NEW HOUSE SEWER
SIGNED THIS DAY OF 19 CONNECT ADDITIONAL
OWNER OR _BUILDING OR WORK
OWNERS AGENT SEPTIC TANK,SEEP, PIT(S)
ADDRESS AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOLI� 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 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. BACKFILL SEPTIC TANKS❑
SIGNATURE SEEP. PIT(S) ❑ CESSPOOLS❑
OF PERMITTEE
JOHN A. LAMBIE, COUNTY ENGINEER VALIDATIOvs.
ROBERT A. WOOD. CHIEF PLBG. INSPECTOR
CK. M.0.
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