HomeMy Public PortalAbout10207 GREEN ST_Sewer__ 7:1101,3 CDT
76A642DCE64211 2 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION FNEAREST
JOHN A. LAMBIE, County Engineer 7 Green St .
WILLIAM A. JENSEN, Supt of Building Gli olMan Ave •
FOR APPLICANT TO FILL IN �� C 1 y
LEGAL
DESCRIPTION LOT NO. 1 OWNER Weber Day,
MAIL
BLOCK TRACT 2711 ADDRESS 5926 Temple City Blvd*
NO. OF BLDGS5'. T 1 52818
SIZE OF LOT NOW ON LOT i CITU t 1 C4,tLX C.,A`j •
USE OF Residenae
BUILDINGS DISTRICT NO. GROUP MAP OCESSED BY
peps-R _ �B+K P G
CONTRACTOR �ryv • `tea ��
ADDRESS South San ambiriel CONNECTI N D 5245 No LVGL.L Jmywo
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CITY TEL N
—�/ STATION DEPTH
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❑ STATE MANHOLE REFERENCE " L` UPPER
REGISTRATION 2525 ❑ COUNTY
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTIONP.L. LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB M.L.TO P.L.
PUBLIC SEWER $5.00 P.C.NO.
Co. . JOB O.
SEPTIC TANK,SEEPAGE PIT OR IMPNON
PITS AND/OR DRAINFIELD 510.00 _
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM @ 53.00
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE
WORK TO HOUSE SEWER @ $3.00
OVERFLOW SEEPAGE PIT.DRAINFI ELD
EXTN..0 ESSPOOL.DRYWELL,MANHOLE @ $5.00
ALTER.REPAIR OR ABANDON HOUSE HWY.OR ST.WIDENING
SEWER OR DISPOSAL SYSTEM @ $3.00 STATE ENCROACHMENT
PERMIT NO.
LF
STRIAL
TE APPROVAL
CHARGES
OWNER"S PERMIT S 2 00
AUTHORIZATION TOTAL FEE ) NECTION CHARGE FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. BURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19_ ..
r? r w .! )
OWNER OR HOUSE SEWER �. F
OWNERS AGENT—nfkW NECT ADDITIONAL
DING OR WORK
ADDRESS
IC TANK.SEEP,PIT(S)
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION /OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLYWITH ALL COUNTYOIN AND STATE LAWS REGULATINGPOOL ❑ DRYWELL ❑PLUMBING ANDSEWE1HEREBYCERIF AT 1 M PROPERLY REGISTEREDAND ORR,REPAIR.SEWER OR
LICENSED AS REq ED BY OS ANGLES COUNTY AND STATE OFAGE DISPOSAL SYSTEM
CALIFORNIA OR T T 1 AM HE LEGAL OWN R OF, AND TEN TOONNECT PLUG AND
RESIDEIN, THE OVE SCRIBED RESIDE PRO RTY. NDON HOUSE SEWER
SIGNATURE FILL SEPTIC TANKS OF PERMTTTE .P S) ❑ CESSPOOLS ❑
V IDATIO� ROBERT A. WOOD
CK. MO.
SUPERVISING MECHANICAL ENGINEER
. CASH
L�'i1,0
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