HomeMy Public PortalAbout9205 LONGDEN AVE_Sewer__ t
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ESUB 32
6A642D APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A.
LAMBIE, COUNTY ENGINEER ADDRESs� 9205 Longden Avenue
COLEMAN W. JENKINS. SUPT. OF BUILDING LOCALITY Tennnlp f-l'itir Cal if -
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NEAREST A A
f.R Or
FOR APPLICANT TO FILL IN
_DESCRIPTION LOT NO. OWNER LEGAL City of Temple City
MAIL
BLOCK TRACT ADDRESS 8__N. KaUffManAV
NO, OF BLDGS.
SIZE OF LOT NOW ON LOT CITY T-
USE_OF_ -q I i fEL. N.-
BUILDINGS DISTRICT NO.1 GROUPI MAP PROCESSED,BY
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CONTRACTORJ57 J d__ ge 'r Cj�jn"o 0 9 (c�
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ADDRESS 135 N. Daisy Avenue CONNECTION DATA
--CITY�-as79 -4051
adena TEL. NO. STATION DEPTH
6
STATE c1c MANHOLE REFERENCE
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UPPER
C-21 V LOWER
LI. N.F NO. 133-TO CLASS
_-Wo-7. DESCRIPTION OFWORKFEE —TYPE OF CONNECTION
LEN
---T-Ho—usESEWER-CONNECTING TO Y. CURB P.L. M.L.TO P,L.
PUBLIC SEWER $5.00 P.C.NO.
SEPTIC TANK,SEEPAGE PIT OR @ $10.00 0
PITS AND/OR C)RA[NFIFLD _CO.IMP.NO. JOB NO.
HOUSE SEWER CONNECTING TO TRUNK PERMIT No. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM $3.00 0
CONNECT-ADDITIONAL BLDG OR AFFIDAVITWAVER 1A
WORN 0 HOUSE SEWER @ $3.00
OVERFLOW SEEPAGE PIT DRAINFIELD �� �— __
uj
I EXTN.,CESSPOOL.DRYWELL, CL
KANHOLF $5.00 HWY.OR ST,WIDENING
,E-R-RERX$R OR ABANDON HOUSE
I A��---- z
Sr SYSTEM
WER OR STATE ENCROACHMENT
PERMIT NO.
INDUSTRIAL
WASTE APPROVAL
---------- CHARGES
OVMER7s PERMIT2; 00
AUTHORIZATION[ TOTAL FEE j
CONNECTION CHARGE FEE
I HAVEAT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR To CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE
PUBLIC SEWER. APPROVALS INSPECTOR'S SIGNATURE
SIGNED THISD Y 7—tem 19U
OWNER OR NEW HOUSE SEWER
T----!�
OWNERS AGENair CONNECT ADDITIONAL
BUILDING OR WORK
SEPTIC TANK,SEEP,PIT(S)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFI510
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITHALL COUNTY
ORD INANCES AND STATE LAWS REGULATING El
PLU M13 ING AND SEWERS. CESSPOOL El 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 DES(.:LRI8Pq RESIDENTIAL PROPERTY. ABANDON HOUSE SEWER
I '
SIGNATURE ,s4/ *
EC
OF PERMrrTEE 1A 1,SEEP.
,.ITFILL,SEPTIC TANKS
S) ❑ CESSPOOLS
VALIDATION JACK R. ALLEN
CK. M.O. Q�A.. SUPERVISING MECHANICAL ENGINEER
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