HomeMy Public PortalAbout6141 IVAR AVE_Sewer__ CITY OF TEMPLE CITY
75-65
6A642D APPLICATION FOR PERMIT
76A 64
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING g`
JOHN A. LANIHIE, County Engineer ADDRESS 6141 N e Ivan Ave.
COLYNIAN W. JENKINS,Sup't. of Building
LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL
DESCRIPTION LOT NO.
�7 OWNER
MAIL
BLOCK TRACT `/ ADDRESS=�Y/1
NO. OF BLDGS. �tL
SIZE OF LOT ��NOW ON LOT CITY TEL. �NO.
USE OF DISTRICT NO. GROUP MAP PROCESSED BY
BUILDINGS e p - BK (P/PGG /y
CONTRACTOR (�U.�1re D.e e�'� Ci..wer �'1 ry�:c �t 0� � r i/
ADDRESS quare bJLm, Ra.�jP7-V�—O.C/ -W-j-�+ ///''' j CONNECTION DATA
2933 Max
CITY e�l1iP TEL. NO. STATION `D�'— DEPTH
LICENSE LICENSE ~� i2 UPPER
N0. CLASS m MANHOLE REFERENCE T
F
NO. GESCR OPT ION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TOd4+ CURB M.L.TO P.L.
1 PUBLIC SEWER C $ 5.00 00 >-
TANK, SEEPAGE PIT OR 7 P.C.NO. d
PITS AND/OR DRAINFIELD @' $1 0.00 CO.IMP. NO. ��J .10B NO.
PTIO
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. O�3 ��
PRIVATE DISPOSAL SYSTEM @ $ 3,00 j ix
CONNECT ADDITIONAL BLDG. OR AFFIDAVIT WAIVEk EASEMENT RECORD.ORD..INSTR.NO. DATE O
WORK TO HOUSE SEWER C $ 3.00
ALTER'
REPA R OR ABANDON HOUSE V
SEWER OR DISPOSAL SYSTEM C $ 3.00 W
_L U HWY. OR ST.WIDENING d
hy
EXT ,CESSPOOL, MANHOLE C $ 5.00 STATE ENCROACHMENT b
PERCOLATION TEST @ $ 5.OG PERMIT NO. e
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT $ 2 00
AUTHORIZATION TOTAL FEE QO 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
TO THE PUBLIC SEWER. APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19_ {�
OWNER OR NEW HOUSE SEWER
OWNERS AGENT
CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP,PIT(S)
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 ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ° ALTER,REPAIR,SEWER OR
CE
LINSEDAS.REOU TED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABOJVgE DESCRIBED RESIDENTIAL ROPE Y. ABANDON HOUSE SEWER
SIGNATURE (J BACKFILL SEPTIC TANKS ❑
OF PERMITTEE SEEP,PIT(S) ❑ CESSPOOLS ❑ -
LIDATION
CK. M.O. CASH
L.)L{ 'v
CE808 3-64
76A642D APPLICATION f'C PERMIT
COUNTY OF LOS ANGELES SEWE -SEMAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUIL�INc
JOHN A. LAMBIE, County Engineer ADDRESS
WILLIAM A. JENSEN, Sup't of Building
LOCALITY
.._.„. _ NEAREST
F R APPLICANT TO FILL IN ..0:r ST. '
LEGAL /•!
DES
CRIPTI LOT NO. OWNER J
MAIL
BLOCK TRACT ADDRESS/7q_7 'Iwz;;
NO. OF BLDGS. /
SIZE OF LOT �� NOW ON LOT ( CITY y4�• TEL. NO. -- S•
USE OF DISTRICT NO.1 GROUP MAP PROCESS D BY o
BUILDINGS
BK PG
CONTRACTOR i
ADDRESS d _ CONNECTION DATA
CITY _52;� TEL. NO. i J STATION DEPTH
� e
STATE MANHOLE REFERENCE UPPER
REGISTRATION NO. LJ COUNTY LOWER
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L.
PUBLIC SEWER @ $5.00 P.C.NO.
SEPTIC TANK,SEEPAGE PIT OR
NJOB NO. a
PITS AND/OR DRAINFIELD @ $10.00 CO.IMP.NO.
O
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. U
PRIVATE DISPOSAL SYSTEM @ S3.00
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT I WAIV[R I [A8[M[NT RECORD.INSTR.NO. DATE O
WORK TO HOUSE SEWER @ $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD ~
EXTN..CESSPOOL,DRYWELL,MANHOLE @ $5.00 U
ALTER•REPAIR OR ABANDON HOUSE HWY. OR ST.WIDENING d
SEWER OR DISPOSAL SYSTEM $3.00 O STATE ENCROACHMENT N
PERMIT NO. Z
INDUSTRIAL
WASTE APPROVAL
OWNER'S PERMIT $ 2 00
AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEE CHARGES
A HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT T-I� ABOVE DESC EXISSING DWELLING
TO THE PUBLIC .Lf .4 APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED T —DAY OF 1
OWNER OR NEW HOUSE SEWER
OWNERS
CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS 4,11
SEPTIC TANK,SEEP,PIT(S)
1 HEREBY AC NOWLEDGE THAT I HAVE READ THI APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AG E TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTI� THAT I AM PROPERLY REGISTERED AND/OR ALTER.REPAIR,SEWER OR
LICENSED AS REQU RED BY LOS ANGLES COUN ND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR I AM THE LEGAL O ER F, AND INTEND TO DISSONNZCT PLUG AND
RESIDE IN, T BO E DESCRIBED RE T ROPERTY. ABANDON HOUSE SEWER
SIGNATURE I BACKFILL SEPTIC TANKS ❑
OF PERMI T SEEP.PIT(S) ❑ CESSPOOLSOE 44
❑
/,—VALIDATION ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
CK. M.O. CASH
LAW
1 3 89c\'D- 0 c T 2 6 1 D 5.00
J