HomeMy Public PortalAbout6241 HART AVE_Sewer__ TEMPLE CITY
76AS42D
CE808 B•SB p ^ yLO Cn
T ® V. FOR P E R M T .
COUNTY OF LOS ANGELES '" SEW S R—SEYWAG E ®0 SPOSA ,
DEPARTMENT OF COUNTY ENGINEER ;;
BUILDING AND SAFETY DIVISION BUILDING
-'. ADDRESS � o2 /IF
JOHN A. LAMBIE, County Engineer
CASSATP D. GRIFFIN, Sup t of Building LOCALITY `�+ �7 (�
CROSS ST. d/✓a /✓-bf-
FOR APPLICANT T9 FILL IN
' LEGAL
DESCRIPTION ,y LOT
OWNER /&47./V
/F./ 16: 19
NO-'.41 -2 MAIL
BLOCK TRACT ADDRESS JnL T�v4 ��
NO.
S,
OF BLDGS. gnES�i4'�
SIZEOF LOT v/1 ( NOW ON LOT CITY Crj TEL. NO. G/i 3USE OF
BUILDINGS L/4' t DISTRICT N0. GROUP MAP - PRO
�� ( BK
CONTRACTOR �
PG r
ADDRESS CONNECTION DATA
CITY TEL.N0. y STATION / DEPTH �-
® STATE ° MANHOLE REFERENCE
c9 REGISTRATION NO. COUNTY I o +
No. DESCRIPTION OF WORK FEE _
HOUSE SEWER CONNECTING TO
`r PUBLIC SEWER @ $3.00 (177 ION LENGTH FROM
u° a TYPE OF CT /
SEPTIC TANK,SEEPAGE PIT OR Y. CURB P.L. M.L.TO P.L.
�- PITS AND/OR DRAINFIELD @ $3.00
' OVERFLOW SEEPAGE PIT,DRAINFIELD
} EXTN'..CESSPOOL. DRYWELL @ $2.00
HOUSE SEWER CONNECTING TOP;C.NO.
x.. PRIVATE DISPOSAL SYSTEM @ S1.00
CO.IMP. N0. JOB NO.
CONNECT ADDITIONAL BLDG.OR k TRUNK PERMIT NO. ROAD PERMIT NO.
WORK TO HOUSE SEWER @ 41.00
GB ALTER'REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
p, SEWER OR DISPOSAL SYSTEM _ @ $1.00 PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OVMER'S PERMIT 5 2 FOO CONNECTION CHARGE FEE
f AUTHORIZATION TOTAL FEE S D tJ ,n REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE/ INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS DAY OF19__ NEW HOUSE SEWER
OWNER OR 2 CONNECT ADDITIONAL
OWNERS AGENT p '' BUILDING OR WORK T
ADDRESS ' �c ':. SEPTIC TANK,SEEP.PIS)
} AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION
° AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL C1 DRYWELL [Ii WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING "�
PLUMBING AND SEWERS. ALTER,REPAIR,SEWER OR
SEWAGE DISPOSAL SYSTEM
LDESCRIBED
CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR G'' DISCONNECT PLUG AND
S REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER "
OR THAT 1 AM THE LEGAL OWNER OF THE ABOVE �`RESIDENTIA PR PERTY. BACKFILL SEPTIC TANKSSEEP.PIT(S) ❑ CESSPOOLS ❑TE
®F VALIDATION ROBERT A. WOOD.
C6.
K.0. CASH SUPERVISING MECHANICAL ENGINEER
2 1 81.0 FSE 13 1 5-.00 T,