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CEBDB 5-55 APPLICATION FO PERMIT
6A642D
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A LAMBIE, County Engineer ADDRESS
COLEMAN W JENKINS, Sup't of Building Temples City
LOCA L,TY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST TrelmWneT Lane
LEGAL
DESCRIPTION LOT NO OWNER & MP$ Fred George
MAIL
BLOCK TRACT z ADDRESS (�
SIZE OF LOT NOWOON LOTS CITY Tem le Crit TEL NO 447-74B6
USE OF _ DISTRICT NO GROUP MAP PROCESSED BY
BUILDINGS -
BK PG
CONTRACTOR D P314b C
ADDRESS 414 So San G b ie 2 CONNECTIO DATA
CITY TEL NO
38® Gabriel At 70579 STATION R DEPTH
LI (] !J CENSE 126935 LICENSE so 42 MANHOLE REFERENCE �O UPPER
LCLASS
LOWER
NO DESCRIPTION OF WORK FEE TYPEOF TION LENGTH FROM
HOUSE SEWER CONNECTING TO Y CURB P L ML TO P IL �sJ
PUBLIC SEWER @ $ 5 00
TI AN E AGE PIT R PC NO
PITS AND/OR DRAINFIELD @ $10 00 CO IMP NO JOB NO 0
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO o _ r ROAD PERMIT NO / U
PRIVATE DISPOSAL SYSTEM C $ 3 00
CONNECT ADDITIONAL BLDG OR AFFIDAVIT NAlvca cISIEMCNT RECORD INSTR NO DATE 0
WORK TO HOUSE SEWER @ $ 3 00
'ALTER, REPAIR OR ABANDON HOUSE
SEWER OR DISPOSAL SYSTEM C $ 3 00 !!IEEE
` HWY ORST WIDENING d
EXTN ,CESSPOOL, MANHOLE @ $ 5 00 STATE ENCROACHMENT y
PERCOLATION TEST @ $ 5 OG PERMIT NO z
INDUSTRIAL
WASTE APPROVAL
OWNERS PERMIT $ 2 00 CHARGES
AUTHORIZATION TOTAL FEE 1 7 1 00 CONNECTION CHARGE FEE
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTINGDWELLING
TO THE PUBLIC SEW APPROVALS DATE INSPECT R'S SIGNATURE
SIGNED THIS I DAY 19G i�ry
OWNER OR n /�� NEW HOUSE SEWER C�
OWNERS AG NT ,�(/�•(/�
� CONNECT ADDITIONAL
BUILDING OR WORK
AO
ADDRESS
SEPTIC TANK SEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION ANO/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITHALL 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 GEES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE EG L OWNER OF AND INTEND TO DISCONNECT PLUG AND
RESIDE IN THE AB E DESC BED E IDEN TIAL PROPERTY ABANDON HOUSE SEWER
SIGNATURE BACKFILL SEPTIC TANKS ❑ G+r
OF PERMITTEE SEEP PITS) ❑ CESSPOOLS
VALIDATIqN----,,
CK M O CASH
07688� W21100 TO