HomeMy Public PortalAbout9518 LOWER AZUSA RD_Sewer__ TEMPLE CITY
>eo8 8.5,9 APPLICATION FOR PERMIT '-
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING'
V y
JOHN A. LAMBIE, County Engineer ADDRESS r""
CASSATT D. GRIFFIN, Supt of Building
LOCALITY 4'
NEAREST
FOR APPLICANT TO FILL IN CROSS ST. '
LEGAL r r
I
DESCRIPTION LOT N0. OWNER
BLOCK TRACTMAIL
ADDRESS'
N0,OF BLDGS,
SIZE OF LOT NOW ON LOT CITY TEL. NO.
USE OF
BUILDINGS DISTRICT NO. GROUP MAP PROCESSED BY
BK PG
CONTRACTOR x ��
ADDRESS �' CONNECTION DATA '
CITY '" TEL.NO. STATION DEPTH
' STATE MANHOLE'REFERENCE UPPER
REGISTRATIOB NO. ❑ COUNTY LOWER
NO. DESCRIPTION OF WORK FEE _
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $3.60 TYPE 6F CONNECTION LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR Y. CURB P.L. M.L,TO P.L.
PITS AND/OR DRAINFIELD $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD
EXTN..CESSPOOL.DRYWELL @ $2.00 -
HOUSE SEWER CONNECTING TOP.C." '
PRIVATF.DISPOSAL SYSTEM @ $1.00 CO. IMP. NO. �'�'` �- JOB
CONNECT'ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAa-PSRMIT NO.
WORK TO HOUSE SEWER @ $1.00 r
ALTER,REPAiR QR ABANDON HOUSE STATE ENCROACHMENT -
SEWER
OR DISPOSAL SYSTEM @ $1.00 PERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNER'S PERMIT $ 2 00 CONNECTIQR'CHARGE FEE
AUTHORIZATION TOTAL FEE r' REIMBCIRSEMENTF£E
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS 1 DATE �INSPECTOR'SSIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS DAY OF 19 __ NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADDRESS SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL ❑
SMITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. ALTER,REPAIR,SEWER OR
SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS GE COUNTY AND STATE OF DISCONNECT
ANDON HOUSE SEWER
CALIFORNIA OR THAT I AM L L� OWNER OF -J�BOYEIAB
DESCRIBED RES DENTAL PR ° BACKFILL SEPTIC TANKS ❑
SIGNATURE
SEEP.PIT(S) 0 CESSPOOLS El
OF FERMITT ✓.
VALIDATION-- ROBERT A. WOOD
CK. Y.C. CASH.' SUPERVISING MECHANICAL, ENGINEER
i.+