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TEMPLE CITY
CE806 5-65
7 6A 642 D APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SLC7ounty�
DIVISION BUILDING
JOAN A. LAAIBIE, ngineer ADDRESS5 'Imar
qCOLE\lAN R'. JENI:INof Building
LOCALITY City
NEAREST
FOR APPLICANT TO FILL IN CRDSB ST Garibaldi �7e.
LEGAL
DESCR1 PT10N LOT NO OWNER Otto'
MAIL " n
BLOCK TRACT ADDRESS 9541 E. Olema St
.
NO OF BLDGS
SIZE OF LOT NOW ON LOT CITfj e �CI_t.V TEL. NO.
USE OF DISTRICT NO GROUP MAP PROCESSED BY
BUILDINGS -
CONTRACTOR If-
-).. ��� . KSqllcqrp
ADDRESS 21J33 Ma,—son Rd . CONNECTION DATA
CITY {- TEL NO 1 ��
STATION r DEPTH
CENSE LICENSE
LI
LCLASS MANHOLE REFERENCE `
J r f� G LOWER
NO. CESCIIIPTION OF WORK FEE TYPE OF CO ION LE GTH" OM
HOUSE SEWER CONNECTING TO Y URB P L M L TO
l PUBLIC SEWER C< $ 5 00 OO }
SEPTIC TANK, SEEPAGE P T R PC NO. a
PITS AND/OR 0RA INFIELD @ $1 0 00 CO.IMP NO JOB NO O
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO j V
PRIVATE DISPOSAL SYSTEM @ $ 3 00
CONNECT ADDITIONAL BLDG OR AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO ATE O
WORK TO HOUSE SEWER @ $ 3 00 H
REPAIR AB N N HOUSE V
SEWER OR DISPOSAL SYSTEM C $ 3 00 W
- LOWHWY OR ST WIDENING G.
TMFIV)
EXTN ,CESSPOOL, MHAG"ANHOLE @ $ 5 00 STATE ENCROACHMENT Z
PERCOLATION TE ST @ $ 5 00 PERMIT NO
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT 21 00 CHARGES
AUTHORIZATION TOTAL FEE ,r OO 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 SEWERAPPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF � 19_
OWNER OR NEW HOUSE SEWER �O
OWNERS AGENT CONNECT ADDITIONAL V
ADDRESS BUILDING OR WORK _
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 F-1DRYWELL El
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSEDAS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER AND INTEND TO DISCONNECT PLUG AND _
RESIDE IN, THE ABOVE DESCRIBED RESIDEN71 P ERTY ABANDON HOUSE SEWER
SIGNATURE A BACKFILL SEPTIC TANKS ❑
OF PERMITTEE �•/�- SEEP,PIT(S) ❑ CESSPOOLS ❑
VALIDATION
CM O CASH
LFLo 1 5 0 0 NOV 1 1 0 D 7.0 0 7