HomeMy Public PortalAbout9845 LA ROSA DR_Sewer__ TEMPLE CITY
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76A 6 8 2/2'T° APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BDILD INC
JOHN A. LAMBIE. COUNTY ENGINEER ADDRESS g 1} E. La Rosa Dr.
COLEMAN W. JENKINS. SUPT. OF BUILDING
NEAREST
Temple Cit
FOR APPLICANT TO FILL IN NEAREST
(PRINT OR TYPE ONLY)
cR055 5T. Baldwin Ave
LEGAL
DESCRIPTION LOT NO. h OWNER rym. )�A Kelley
MAILBLOCK TRACT n� MAIL
ADDRESS V4 E. La Rosa Dr
SIZE OF LOT NOW ON LOTBLDG S G CITY Temple Cit TEL. NO-
USE
QVSE
BUILDINGS
Res . & Gar.NGS 1] DISLq ICT NO. Gg011P CLA55 I
L MAP P3 PgOCE,55El/D BY
OM
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CONTRACTORSt)'a2^P Deal Sewer Service vq I O !Y L /^G
ADDRESS 2933 Maxson Fid. CONNECTION DATA
CITY 7 M TEL. NO. 444-2040 STATION 'Z y DEPTH
5TATE 288 O LIC CLP 55 C-4'2 V UPPER
LICENSE NO. MANHOLE REFEflENCE
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LEAS T FROM ./
HOUSE SEWER CONNECTING TO Y. CURB P.L. � M.L.T P.L. 3
1 PUBLIGSEWER ® -.Bi06� OO
SEPTIC LANK.SEEPAGE PIT OR A/ .J)4n (L+� P.C.NO.
PITS ANO/OR GRAINFIELD 0 310.OD CO.IMP. NO. 'v (� JOB NO.
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO, ROAD PERMIT NO. }
PRIVATE DISPOSAL SYSTEM ® 33.00 CL
1 CONNECT ADDITIONAL BLDG.OROO AFFIDAVIT w.ryu a[.[ RECORD.INSTR.NO. DATE 0
WORK TO HOUSE SEWER 3300.
OVERFLOW SEEPAGE PIT.DRAINFIELD
EKTN..CESSPOOL,DRYWELL.MANHOLE a SS.00 0
ALTER.REPAIR OR ABANDON HOUSE HWY. OR ST.WIDENING _ F
SEWER OR OISPOSAL SYSTEM V $3.00 STATE ENCROACHMENT V
Py C PERMIT NO. W a
INDUSTRIAL 'Al
WASTE APPROVAL Z_
CHARGES
OWNERS PERMIT'
s o0
AUTHORIZATION I TOTAL FEE 1 131 OO CONNECTION CHARGE FEE
1HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS
TO THE PUBLIC SEWER, DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19
OWNER OR NEW HOUSE SEWER ^�O�
OWNERS AGENT CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
SEPTIC TANK.SEEP.PIT(5)
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 ❑
IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER.REPAIR.SEWER OR
LICENSED AS REOUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE OISPOS AL SYSTEM
CALIFORNIA OR THAT 1 AM THE LEGAL HER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE ABOV�E//JDESCRIBED RES ENT AL PROPERTY. ABANDON HOUSE SEWER
SIGNATURE
PERMITTEE a BACHFILL 3RSYLL'rTYM[YB�
ff
VALIDATION JACK R. ALLEN
M.O. CASH
SUPERVISING MECHANICAL ENGINEER
CK.
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