HomeMy Public PortalAbout9827 KEY WEST ST_Sewer__ -TEMPLE CITY
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cEsos om8-59• APPLICATION FOR PERMIT
E906
COUNTY OF LOS ANGELES $EWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION TBUILDING
DDRESS We
JOHN A. LAMBIE, CountF Engineer /.
CASSAIT D. GRIFFIN, Supt of Building OCALITY EARESTFOR APPLICANT TO FILL IN ROSS ST. el
LEGAL - A OWNER
DESCRIPTION LOT N0. •
BLOCK TRACT �i MAIL
ADDRESS
avrq NO OF bLDGSfj
SIZE OF LOT NOW ON LOT �us CITY L NO 16
USE OF DISTRICT N0. ROUP MAP PROCESSED BY
BUILDINGS C9 PG I
CONTRACTOR
ADDRESS r`. '•% v, J Q CONNECTION ATA
CITY r N0. n STATION DEPTH
` STATE MANHOLE REFERENCE
REGISTRATION O COUNTY LOWER
No. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3 00 TYPE OF CTION •LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR y, RB P.L. M.L.TO P.L.
PITS AND/OR DRAINFIELD @ $3 00
OVERFLOW SEEPAGE PIT,DRAINFIELD
EX N. CESSPOOL DRYWELL @ $2 00
HOUSE SEWER CONNECTING TO P.C.NO. -
PRIVATE DISPOSAL SYSTEM @ $1-00 CO.IMP.NO JOB NO.
CONNECT ADDITIONAL BLDG OR TRUNK PERMIT NO. ROAD PERMIT NO.
WORK TO HOUSE SEWER @ $1 00
SEWER OR DISPOR OSAL SYSTEM HOUSE @ $1 00 STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL _
CHARGES
OWNER'S PERMIT $ 2 00 CONNECTION CHARGE FEE - \
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE 6
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- I
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVAL$ DATE - INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER. �•�
SIGNED THIS DAY OF 19— NEW HOUSE SEWER %%P6OWNER OR s
OWNERS AGENT - CONNECT ADDITIONAL •r' /' f
BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL [I DRYWELL ❑
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM T LEGAL OWNER OF THE ABOVE
DESCRIBED NTI L PROPE BACKFILL SEPTIC TANKS ❑
SIGNATURE ,/ EEP PIT(S) ❑ CESSPOOLS
OF PERMITTE y -
®r �— VALIDATION ROBERT A. WOOD
CIL M.o, CASH SUPERVISING MECHANICAL ENGINEER
NV6 0 ; 4 9 ZEC 2 7 1 0 p 5.0 0 n