HomeMy Public PortalAbout5333 LOMA AVE_Sewer__ TEMPLE CITY
21.70
76A6A 642q• APPLICATION FOR PERMIT
6
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT'OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING 5333 N Loma
JOHN A. LAMBIE. COUNTY ENGINEER ADORERS
COLEMAN W. JENKINS. SUPT OF BUILDING
Locnurr City
FOR APPLICANT TO FILL IN NEAREST
cRoss sr Olive St
(PRINT OR TYPE ONLY)
LEGAL
DESCRIPTION LOT NO OWNER Paul Friedman
MAIL 23 04 N. Lee Ave.
BLOCK TRACT ADDRESS
SIZE OF LOT NOWOON LOTS CITYSO . El MOnteEL. NO.
USE OF Res.BUILDINGS es. DISTRICTNO GROUP CLASS MAP ;PROCESSED BYpGCONTRACTOR S uare Deal Sewer ,SerViC �'D � i� .
ADDRESS 2 Maxson Rd, CONNE TION D TA
CITY El Monte TEL NO. 444--2020 STATION n, DEPTH
STATE LIC
LICENSE NO. 1.28870 CLASS c- MANHOLE REFERENCE �/
(J � LOWER
NO. .DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FR6m
HOUSE SEWER CONNECTING TO Y CURB P.L. M L TO P L
PUBLIC SEWER $5 00
SEPTIC LANK SEEPAGE PIT OR P.0 NO.
PITS AND/OR DRAINFIELD 51000 CO IMP.No JOB NO
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO d
PRIVATE DISPOSAL SYSTEM $306 - 0
1 CONNECT ADDITIONAL BLDG OR AFFIDAVIT WAIV[t -IASINI'T RECORD INSTR NO DATE V
WORK TO HOUSE SEWER 53.00 00
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN CESSPOOL.DRYWELL MANHOLE(0 $500 HWr OR ST WIDENING 0
ALTER.REPAIR OR ABANDON HOUSE H
SEWER OR DISPOSAL SYSTEM $3.00 STATE ENCROACHMENT W
PERMIT NO.
INDUSTRIAL
����+pNERWASTE APPROVAL D Z
OWNER'S PERMIT S 00 ilt
CH RGES
CONNECTION•CHARGE FEE.
AUTHORIZATION TOTAL FEE C OO
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 ATE INf4P CTO R'S SIG ATU RE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT
CONNECT ADDITIONAL
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 15 CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR.SEWER OR
LICENSEDAS REQUIRED BY LOS ANGLES COUNTY AN STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF.
AN INTE STATE.
TO DISCONNECT PLUG AND
RESIDE IN THE ABOVE DESCRIBED RESIDENTIAL PRqfERTY ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑ '
OF PERMITTEE SEEP.PIT IS) ❑ CESSPOOLS ❑
CC
VALIDATION JACK R. ALLEN
SUPERVISING MECHANICAL ENGINEER
M.O CASH
CACo 4 9 91 KAR 7 1 0 0 6.0 0 .
y.
642D 2/.70
76A I: - APPLICA /NFOR PERMIT {�
76A.
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING p�
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS 1
COLEMAN W. JENKINS. SUPT OF BUILDING r
LOCALITY l�
FOR APPLICANT TO FILL IN NEAREST D )r
(PRINT OR TYPE ONLY) CROSS ST ��
FU
GAL
RIPTION LOT NO OWNER
MAIL
K TRACT ADDRESS
_ NO OF BLDGS ++ /
OF LOT • �Q NOW ON LOT 1 -- CITY TEL. NO
OF
INGS DISTRICT NO GROUP CLASS MAP P OCESSED BY
BK PS
CONTRACTOR
ADDRESS �� V /•CONNECTION 15ATA
�,/}} ! O STATION /
CIT'f�i1 j � TEL NL DEPTH...---qqq ��f
STATE LIC -'� MANHOLE REFERENCE�� UPPER
LICENSE NO�i-�-3_� GLASA� LOWER]
NO DESCRIPTION OF WORK FEE TYPE OF CONNECTIO LENGTH FROM
HOUSE SEWER CONNECTING TO Y CURB P L. M.L.TO P L
PUBLIC SEWER @ SS 00
SEPTIC LANK SEEPAGE PIT OR P C NO.
PITS AND/OR DRAINFIELD @ $1000 CO IMP.NO. JOB NO.
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO >_PRIVATE DISPOSAL SYSTEM Q $300 d
CONNECT ADDITIONAL BLDG ORA1Y111 EA11M[NT RECORD.INSTR NO DATE O
WORK TO HOUSE SEWER @ $300
v
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN CESSPOOL DRYWELL MANHOLE @ S5 00
ALTER,REPAIR OR ABANDON HOUSE HWY OR ST.WIDENING O
SEWER OR DISPOSAL SYSTEM $3 00 �� STATE ENCROACHMENT V
PERMIT NO W
INDUSTRIAL CL
toWASTE APPROVAL to
OWIT
OWNER'S PERMa Oo CHARGES
AUTHORIZATION I TOTAL FEE y CONNECTION CHARGE FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON1 REIMBURSEMENT FEE
TRACTOR-TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC BE R �7 APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS �F DAY OF � Ig1�
OWNER OR _��-/(� y� NEW HOUSE SEWER
OWNERS AGENT /�\'4 �� �I/•/ CONNECT ADDITIONAL
ADDRESS jy� 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 15 CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING El
AND SEWERS. CESSPOOL ❑ DRYWELL
I HEREBY CERTIFY AT I M PROPERLY REGISTERED AND/OR ALTER,REPAIR.SEWER OR
LICENSED AS REOUIR D BY'� OS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR TH T AM E LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE AB D I RI ED RESIDENTIAL PROPERTY n,
.i ABANDON HOUSE SEWER
SIGNATURE / '�..i� BACKFILL SEPTIC TANKS ❑
OF PER."TEE SEEP PITIS) ❑ CESSPOOLS Ell I
i- �
TIONJACK R. ALLENSUPERVISING MECHANICAL ENGINEER
CASHGn
H
1t,� o� DEC 15 1. 0 D 6.0 0
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