HomeMy Public PortalAbout9527 LA ROSA DR_Sewer__ 7 TEMPLE CITY
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76A642D APPLICATION FOR PERMIT
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COUNTY OF LOS'ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING 9527 E La Rosa Dr.
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS •
COLEMAN W. JENKINS. SUPT OF BUILDING LOCALITY Temple Cit
NEAREST Temple City Blvd.
FOR APPLICANT TO FILL IN CRASS BT
LEGAL Lewis C. Woodland
DESCRIPTION LOT NO. 7 OWNERMAIL
BLOCK TRACT j �� ADDRESS 9527 E• La Rosa Dr•
NO OF BLDGS.
SIZE OF LOT NOW ON LOT 1 'CITY • C. TEL. NO.
USE OF Res• DISTRICT NO. GROUP MAP PROCESSED BY
BUILDINGS BK� Pj
CONTRACTOR Square Deal Sewer Service ,�v
ADDRESS 2933
2933 Maxson Rd.'. f] CONNECTION DATA
CITY El Monte TEL NO. 444-2020 STATION / DEPTH $--/
STATE (UPPER
LICENSE NO.. 128870 C�SS C-4.2 MANHOLER j2ENj f� ' LOWER
NO .DESCRIPTION OF WORK FEE TYPE
1 PUBLIC O C CTION LENGTH PFRO
RBOCONNECTING TO Y P L M.LTO
SEWERSS 00 5 OO
S
CL
SEPTIC TANK,SEEPAGE PIT OR P.G.NO. 0
PITS AND/OR ORA INFIELD @ S1000 CO IMP NO. � JOB NO. V
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO. /� p�
PRIVATE DISPOSAL SYSTEM @ $300 / O
CONNECT ADDITIONAL BLDG OR AFFIDAVIT WAIV [ASEM[NT RECORD INSTR NO DAT I.-
WORK TO HOUSE SEWER @ $300 u
OVERFLOW SEEPAGE PIT.DRAINFIELD
M
EXTN CESSPOOL DRYWELL MANHOLE @ $500 N
ALTER.REPAIR OR ABANDON HOUSE
HWY OR ST WIDENING Z
SEWER OR DISPOSAL SYSTEM @ $3 00 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT S 2 00
AUTHORIZATION TOTAL FEE 7100 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 IN ECTOR'S SIG ATURE
SIGNED THIS
_/�� 1) OF O^F 19 - z
OWNER A - Ji _ j/ //a1 / NEW HOUSE SEWER /�7
OWNERS AGENT/Y����pY 1' y l4'W/ CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS SEPTIC TANKSEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAT NFIELD
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
LICENSED AS REQUIRED 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 ABOVE DESCRIBED RESIDENTIA PROP RTY ABANDON HOUSE SEWER '
SIGNATURE
APERMTTTEE BACKFILL SEPTIC TANKS ❑
SEEP,PIT(S) ❑ CESSPOOLS
VALIDATION JACK R. ALLEN
CK M O CASH SUPERVISING MECHANICAL ENGINEER