HomeMy Public PortalAbout10134 GREEN ST_Sewer__ 0-63
76A642D APPLICATION FOR PERMIT
6A642
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County Engineer ADDRESS
WILLIAM A. JENSEN, Supt of Building
LOCALITY
NEAREST
FOR APPLICANT TO 7LL
IN CROSS 5T• J
LEGAL �*t,A
DESCRIPTION LOT NO. 0 7v4OWNER ./ F e
J/ ZZR
m - �" MAIL )
y(}bSGIL, RACT A ! �Q ADDRESS �(=/1i
A, `iO_Q NO. OF BLDGS.
SIZE OF LOT NOW ON LOT CITY I; TEL. NO.
USE OF DISTRICT NO. GROUP MAP PROCES BY
BUILDINGS
BK PG
CONTRACTOR O �^ Z
ADDRESS 1j 04CONNECTION DATA
CITY P TEL. NO. 3 -.& STATION ( ' DEPTH ,
!STATE PIPER
/• MANHOLE REFERENCE
REGISTRATION NO. ❑ COUNTY
NO, DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH OM
[HOUSE SEWER PUBLIC SEWER CONNECTING TO $5.00 �� Y. CURB .L. M.L.TO P.L. 3O d
SEPTIC TANK,SEEPAGE PIT OR P.C.NO: fyQ /'•� O
PITS AND/OR DRAINFIELD @ $10.00 NO. ��// /
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NOS--� gx
PRIVATE DISPOSAL SYSTEM @ $3.00 0
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAI rl rASIMINT RECORD.INSTR.NO. DATE G
WORK TO HOUSE SEWER $3.00 7� _
OVERFLOW SEEPAGE PIT.DRAINFIELD
EXTN.,CESSPOOL.DRYWELL,MANHOLE @ $5.00
ALTER,REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING N
SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
OWNERS PERMIT z o0
WASTE APPROVAL
CHARGES
t
AUTHORIZATION TOTAL FEE z 12
0-0 CONNECTION CHARGE FEE
'I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRI D EXISTING DWELLING APPROVALS
TO THE PUBLIC SEW DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19 w
OWNER OR NEW HOUSE SEWER 1/ ! -
OWNERS AGENT CONNECT ADDITIONAL
d l BUILDING OR WORK J
ADDRESS SEPTIC TANK.SEEP,PIT(5)
I
HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
IHEREBY 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 I A LEGAL OWNER O ITEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABOV ESC B D RESID NTIAL RO Y. gBANDON HOUSE SEW ER
SIGNATURE J BACKFILL SEPTIC TANKS ❑ ,.q I
OF PERMITTEE SEEEr,�T(S) ❑ CESSPOOLS `71 („-i :iVALIDATION 15 R BE r A. woo
SUPERVISING MECHANICAL NGINEER
OC
M. O. CASH
lb 0 2 0 Jul-2 7 11 0.0 0,
COUNTY OF LOS ANGELES TEMPLE CITY f D508 SEWER PERMIT
DEPARTMENT OF PUBLIC WORKS 9071 LAS TUk&S SE 0508 9612120032
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA
PHONE: (818) 285-0488 EXT:
LEGAL ID: SEWER SEPTIC: S BUILDING ADDRESS. -
ON FILE EXIST OCC GRP: R3 10134 GREEN ST
BLDGS. NOW ON LOT: TEMP CA 917803333
AgnTOFIN FORMAT ION NUPSER: CONNECTION TYPE: NEAREST CROSS STREET:
8585-007-066 ORIGINATION: THOMAS PAGE: 597 GRID: B4 LOCALITY: TEMPLE CITY
LENGTH ML TO PL: STATION: DEPTH:
MANHOLE REFERENCE: UPPER/LOWER: I JED ON: PROCESSED BY: EXPIRES .
-
COUNTY IMPROVEMENT NUMBER:. 12/12/96 TC 12/12/97 •
PLAN CHECK NUMBER: FINAL DA FINAL BY:
SELDERS TIM;KATHRYN (818) 448-8120- JOB NUMBER:
10134 GREEN ST TRUNK PERMIT NUMBER:
TEMP 917803333 ROAD PERMIT NUMBER:
AFFADAVIT: NO ^ REPLACE MATELY 401 OF 40 SEWER LIME WITH 4° ABS PIPE
WAIVER: NO
APPLICANT: TEL. NO: EASEMENT: NO �!�'�'��~ �•3��'�,
SAME AS OWNER
RECORD INSTRUMENT^NBR: -—REttORD-DAT-k.� , 1+ SPECIAL CONDITIONS:
HIGHWAY/STREET WI5EIHMG:.
STATE EMCR0ACrEEN7`pERMIt.WU�MBER: `,rAl
j
CONTRACTOR: TEL. NO: t.NU
SAME AS OWNER - !, �.' . ` .
LIC. NO FEE DESCRrq} IO4 / � jLI�iTITY: LEM: _ A'!°� �,
01 PERMIT ISSUANCE, FEE. -- - - - - - -27:75 o CONNECT ADDITIONAL
15 ALT/REP HOyS� EWEIt: ;1;.D0 30.30 BUILDING OR WORK
ARCHITECT
• _ �,''�PTAL',;FEES56.05
SEPTIC TANK, SEEPAGE PIT
LIC. N0: . G j w ui --�—_- '� AND/OR DRAIN FIELD
DRYWELL
REPAIR
S 128 fs' `? ��` ;�. -4] f; r' !1 �J §EWAGE DISiO L SYSTEM
,•a ' _ % ��, %i' -
ABANDON HOUSE SEWER
BACKFILL SEPTIC TANKS
,may 1 SEEP. PIT — CESSPOOL —
GPA
REPORT ID: DPR266 ROUTE TO B30508