HomeMy Public PortalAbout9629-9633 LAS TUNAS DR_Sewer__ y
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16A642 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILNG LBB �1X1�e]Ei �r1VC
JOHN A. LAMBIE, COUNTY ENGINEER 31 ra�R 5 I
COLEMAN W. JENKINS, SUPT. OF BUILDING LOCALITY Temple City
NEAREST
FOR APPLICANT TO FILL INCRD55 5T. � --LEGAL Dominio Mortellero
DESCRIPTION LOT NO
__DESCRIPTION___ _ _ ",{�J -'/--�•. _OWNER__
-_ MAIL
BLOCK TRACT ly. ADDRESS
NO. OF BLDGS, --- -
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF-____-__
BUILDINGS DISTRICT NO. GROUP MAP PROCESSED BY
SK
PG
CONTRACTOR l/nWC[I�L 1g7J�I OS� pD^�tyhy�i7lgj��y>,ry_
ADDRESS 4265 .North Baldwin. Ave. �---eF- ___ CONNECTION DATA
STATION '� '✓ .DEPTH
CITY { _A'ff...,,2TEL. NO, ,W
STATE Ll �— '--"-
MANHOLE REFERENCE A
LICENSE NO. �( CLASS li >`� q � `�.-� LOWER
NO. DES C RI PTIO'N OF WORK FEE _ TYPE OF CONNECT] LENGTH FROM/ ✓ o�,�
tHOUSE SEWER CONNECTING TO Y. CURB P L j M.L.TO P.L.
1 PUBLIC SEWER @ $5.00 I -
SEPTIC TANK SEEPAGE PIT OR ! P.C.NO, O
CO.IMP. NO. ��� JOB NO. (�2
PITS AND OR DRAINFIELD _C $IO.OD. + -
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM @ $3.00 I O
CON NECK ADDITIONAL BLDG OR _ gFFIDAViT 7 wAfvER.EASEMEXi RECORD.INSTR.NO. DATE '>•"'
WORK TO HOUSE SEWER $3.00 u
_ _.-_ __ ---_- xu
OVERFLOW SEEPAGE PIT.DRAINFIELD I
- EXTN..CESSPOOL,DRYWELL.MANHOLE @ $5.00 (?;!
HWY.OR ST.WIDENING ALTER,REPAIR OR ABANDON HOUSE z
SEWER OR DISPOSAL SYSTEM $3.00 -'--
STATE ENCROACH MENT
PERMIT NO.
----------- ----- -^i INDUSTRIAL
WASTE APPROVAL
OWNER'S PERMIT _S 2. oo — --
CHARGES
-�- CONNECTIONCHARGE FEE
AUTHORIZATION TOTAL FEE 7 100 -- — —
1 HAVE 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 INSPECTOR'S SIGNATURE
SIGNED THIS DAY OF 19_ ---"`
OWNER OR NEW HOUSE SEWER _
OWNERS AGENT_ CONNECTA6DITIONAL
BUILDING OR WORK
- -- - - -- "'- SEPTIC TANK.SEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT 1 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
PL.UMSING 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 V SCRIBED RESID lAL PROPERTY. ABANDON HOUSE SEWER
SIGNATURE
OF PERMITTEE ! BACKFILL SEPTIC TANKS ❑ ❑J
'- - -- - -- ---'---- SEEP.PITEl CESSPOOLS
VALIDATION JACK R. ALLEN
M.D. CASH
SUPERVISING MECHANICAL ENGINEER