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HomeMy Public PortalAbout4934 HELEO AVE_Sewer__ TEMPLE CITY <2° CE808 8-59 APPLICATION FOR PERMIT 7 COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL 1 DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION BUILDING a ADDRESS JOHN A. LAMBIE, County Engineer , CASSATT D. GRIFFIN, Supt of building LOCALITY e- NEAREST FOR APPLICANT TO F14,IN CROSS ST. LEGAL I T �_ DESCRIPTION LOT NO.-" , I/ '�- OWNER_ MAIL BLOCK TRACT' = ` c ADDRESS NO.OF BLDGS. SIZE OF LOT NOW ON LOT "^ CITY TEL. N •i-=-+- USE OF / BUILDINGS BK PGDISTRICT NO. GROUP MAP - PROCESS Y 6'C�' ,�-l �d �•^ � (r/ S CONTRACTOR i E'• _ ` �) 7� I I ^� ADDRESS CONNECTION DATA f/.TE/L.NO."" fa J ❑'•/ v ION DEPTH C '- r� /fl�~ ❑ COUNTY STATE MANHOLE REFERENCE C' REGISTRATION NO. LOWER ' No. DESCRIPTION OF WORK FEE --� + HOUSE SEWER CONNECTING TO PUBLIC SEWER @ ? TYPE F 0 ON LENGTH FROM SEPTIC TANK,SEEPAGE PIT OR 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 TO P.C.NO. PRIVATE DISPOSAL SYSTEM @ $1.00 CO,IMP. N0. JOB NO. CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT NO. WORK TO HOUSE SEWER @ $1.00 • ALTER,REPAIR OR ABANDON HOUSE STATE ENCR CHMEN ;�•' " SEWER OR DISPOSAL SYSTEM @ $1.00 PERMIT INDUSTRIAL WASTE APPROVAL CHARGES OWNER'S PERMIT $ 2 00 CONNECTION CHARGE FEE AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE CON- TRACTOR TO CIONNECT THE ABOVE DESCRIBED EXIISTDATE A CONTRACT WITH THE II GAMED DWELLIING APPROVALS DATE INSPECTOR'S SIGNATURE TO THE PUBLIC SEWER. SIGNED THIS DAY OF 19__ NEW HOUSE SEWER OWNER OR CONNECT ADDITIONAL OWNERS AGENT BUILDING OR WORK ADDRESS SEPTIC TANK,SEEP.PIT(S) AND/OR DRAINFIELD I HEREBY ACKNOWLEDGE THAT 1HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL ❑ WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM 1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER CALIFORNIA OR THA Tp M THE LEGA- OWIPEtB�F- THE ABOVE DESCRIBED RESIDEN AL P,l20PERTY BACKFILL SEPTIC TANKS ❑ r - SEEP.PIT(S) ❑ CESSPOOLS ❑ SIGNATURE -. - •,.�� �. OF PERMITTEE J11. ®' VALIDATION ROBERT A. WOOD C j Y.G. CASH SUPERVISING MECHANICAL ENGINEER =La 9 9 4 8" SEP 10 1 0 0 7.0 O^' 4 n' TEMPLE, CITY AT�ON FOR � � . CE908 9$9 _ � - COUNTY OF LOS ANGELES SEWER—SEWAGE ®U S POSH L DEPARTMENT OF COUNTY ENGINEER ;.. BUILDING AND SAFETY DIVISION BUILDING J ADDRESS JOHN A. LAMBIE, County Engineer CASSATT D. GRIFFIN, Supt of Building LOCALITY ,_.,....,. -...... NEAREST FOR APPLICANT TO FILL IN CROSS ST. LEGAL _ DESCRIPTION LOT N0.~ �33 OWNER - ,7;? "*`!;. BLOCKTRACT ;'r '? C"' - MAIL .:�' ADDRESS 4'.r ., NO.OF BLDGS. �9-4 SIZE OF LOT NOW ON LOT CITY ��' • TEL. NO. USE OF c r BUILDINGS. ��..%� ��" < , DI�ST^RICTeNNOO. GROUP BK .MAP PG FROCES yBYr CONTRACTOR ] 14 aDDREs� r �, ,L,,� f �✓ k CONNECTION DATA - C[TY r LL�f� TEL.NO. f✓;: ION 4 DEPTH �� STATE MANHOLE REFERENC �. REGISTRATION NO. � ,:.�- .fie'' ❑ COUNTY A LOWER NO. DESCRIPTION OF WORK FEE HOUSE SEWER CONNECTING TO j. PUBLIC SEWER @ $3.00 TYPE F C T N LENGTH FROM a SEPTIC TANK,SEEPAGE PIT OR .L: M.L.TO P.L. �rj PITS AND/OR DRAINFIELD @ $3.00 . i. OVERFLOW SEEPAGE PIT,DRAINFIELD EXTN..CESSPOOL. DRYWELL @ $2.00 HOUSE SEWER CONNECTING TO P.C.NO. PRIVATE DISPOSAL SYSTEM '@ $1.00 CO.IMP. N0. JOB NO. CONNECT ADDITIONAL BLDG.OR WORK TO HOUSE-SEWER @ $1.00 TRUNK PERMIT N0. ROAD PERMIT N0. ;q `S ATTER,REPAIR OR ABANDON HOUSESTATE fNCROA MENT % _ SEWER OR DISPOSAL SYSTEM @ $1.00 PERMIT N0. " s INDUSTRIA - WASTE APPROVAL CHARGES r OWItRIS PERMIT $ CONNECTION CHARGE FEE AUTHORIZATION I TOTAL FEE CtV 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 OF 19_ NEW HOUSE SEWER IILO OWNER OR CONNECT ADDITIONAL OWNERS AGENT BUILDING OR WORK ADDRESS SEPTIC TANK,SEEP.PIT(S) E?. AND/OR DRAINFIELD 1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION -AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY " CESSPOOL ❑ DRYWELL ❑ WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR PLUMBING AND SEWERS. ALTER, DISPOSAL SEWS OR I HEREBY CERTIFY THAT I AM PROPERLY ERED AND/OR SEWAGDISCONNECT PLUG AND LICENSED AS REQUIR_ -BY LOS ANGEtES�COUNTEM Y D STATE OF - CALIFORNIA OR TH I IAM THE LEGAL-OWNER OF THE ABOVE ABANDON HOUSE SEWER DESCRIBED RESIDEN IAL ElElROPERTY. © BACKFILL SEPTIC TANKS El SIGNATURE `• -r r SEEP.PIT(s) CESSPOOLS OF PERMITTE ��' �� � ��� ®r ALIDATION ROBERT A. WOOD M.G. CASH SUPERVISING MECHANICAL. ENGINEER 99 4:9G SEP10 11 D. 2. 5Z,,C��