HomeMy Public PortalAbout9159 LA ROSA DR_Sewer__ J CITY OF TEmw CITY
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7 6 A 642D APPLICATION FOR PERMIT
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COUNTY OF'IrOS ANGELES SEWER-SEWAGE, DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDI NG� 1K7$a
JOHN A. LAMBIE, County Engineer ADDRESS C "
WILLIAM A. JENSEN, Sup't of Building LOCALITY Temple-Cit
NEAREST �'yCyQ ;NO.FOR APPLICANT TO FELL IN CRDSS STllaLEGAL
DESCRIPTION LOT NO OWNER �jOImuni2833.7 MAIL28} pBLOCK TRACTq����i•OO//.1./ d""" ADDRESS I®llv0E11US89
SIZE OF LOT 210= NOW OON LOTS Ione CITY 0. �te TE � �
USE OF R�.,.'1• DISTRICT NO GROUP MAP PROCESSED BY
BUILDINGS VJINILL "'� /T - rf/� y� BK PG
CONTRACTOR JLeetb PIl'mIbih ` o L<�` S-1,23
ADDRESS ��((2W 19. 'fee Ave.' CJ CONN//E]]CTION DATA
CITY El MOntne7 eeeyyy��. TEL. NO GI 66 STATION U� DEPTH
21 C-36 STATE
COUNTY MANHOLE REFERENCECQa'� O p
REGISTRATION NO �'S l ')
NO DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM 1�
HOUSE SEWER CONNECTING TOC M Y CURB .L M.L.TO P.L J
PUBLIC SEWER @ $S 00 J 00 }
SEPTIC TANK,SEEPAGE PIT OR P C NO J O
PITS AND�OR DRAINFIELD @ $10.00 CO.IMP NO
V
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO,
PRIVATE DISPOSAL SYSTEM @ $300
CONNECT ADDITIONAL'BLDG OR AFFIDAVIT WAIVER EASEMENT RECORD INSTR NO DATE O
WORK TO HOUSE SEWER @ $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD lJ.l
EXTN,CESSPOOL,DRYWELL,MANHOLE SS 00
ALTER.REPAIR OR ABANDON HOUSE HWY OR ST WIDENING h
SEWER OR DISPOSAL SYSTEM E3 00 STATE ENCROACHMENT `
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT $ 2 Do CHARGES
AUTHORIZATION TOTAL FEE CONNECTION CHARGE FEE
-IHAVE 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 INS P ECTO '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)
1 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 ❑
'IHEREBY CERTIFY THAT I AM PROPER REGISTERED AND/OR ALTER.REPAIR,SEWER OR
LICENSED AS REQUIRED BY LOS ANGLE OUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT 1 THE LEGA W ER O TEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABOV SCRIB I NTIA PROPE RT ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTI❑C TANKS ❑
OF PERMITTEE ❑
SEEP.PIT(S) CESSPOOLS
VALIDATION ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
CK. M O CASH
APR 1.5 1 0 D 7.0.0-