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5A 642D APPLICATION FOR PERMW
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
U I LDING
"'J'"', �2.
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS I!:
COLEMAN W. JENKINS. SUPT. OF BUILDING LOCALITY
FNEAREST
FOR APPLICANT TO FILL IN CROSS ST�
(PRINT 'DR TYPE ONLYl
L
--DESCRIPTION LOT NO. OWNER
M-A 1 7
BLOCK j IRA ADDRESS
NO, OF BLOCS.
SIZE OF L-01 NOW ON LOT CITY TEL. NO.
USEOF
BUIL.iNGS DISTRICT NQ]!SROUP (LASS ?AAP PC,
8K
CONTRACTOR J
7
ADD RE St;-?; CONNECTION DATA
J�
STATION 11
TATF DEPTH
c
TEL N -1--Zli
-- /6-
9C
MANHOLE REFERENCE
NO.
No. DESC IPT ON OF WORK FEE TYPE OF CO TION LENGTH FROM
M.L.TO P.L.
HOUSE SEWER CONNECTING TO� URB P.L,
PUBLIC SEWER • P.C.NO.
f --IC-fANK75EEPAQF PIT OR CO. IMP. NO. JOB NO,
PITS AND/OR DRAINFIELD @ $10.00 2-
TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE D15POSAL SYSTEM $3.00
-- -17---- --k.- -- C.
CONNECT ADl�iONAL:-BLDGOR-----'----- AFFIDAVIT' WM�Tl AM�11.T , REC. 714STR.N
K TO HOUSE-.SEWER @ $3.00 u
-FXTN_.CESSPOOL,DRYWELL,MANHOLE $5.�0i0
At TER,REPAIRORHOUSE HWY. OR ST.WIDENING 0
SEWER.gR DISPOSAL SYSTEM
STATE ENCROA
PERMIT'
ELI
7 NO, CL
INDUSTRIAL
WASTE APPR Ly z
OWNER'S PERMIT $ 00 CHARGES
AUTHORIZATION TOTAL FEE 0 0 CONNECTION CHARGE FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- R-EiMBURSEMENTFEE
TRACTOR TO
CONNECT THE ABOVE DESCRIBED EXISTING DWELLINLG
ITHE PUBLIC SEWER.
() APPROVALS DATE I INSPECTOR'S SIGNATURE
SIGNED THIS-DAY OF-
OWW RRA OR NEW HOUSE SEWER
SAGF
CONNECT ADDITIONAL
BUILDING OR WORK
1111 E S 5
.
I ACKNOWLEDGE THAT I HAVEWE-A-0—THS
-IAPPLICATION--- SEPTIC TANKSEEP,PIT(S)
AND/OR DRAtNFIELD
AN D STATE THAT THE
F ABOVE 15 CORRECT AND AGREE TO
COMPLY
WITH
ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING
fNG AND SEWERS, CE55POOL ❑ DRYWELL LJ
I HEREBY CERTIFY THAT I AM PROPERLY f?EGIST ALTER.REPAIR.SEWER OR
�R-D.TANDICR
_F 'r
L 5:N E 0 REQUIRED By LO ANGLES NT, A SEWAGE DISPOSAL SYSTEM
'D
N I rA r, INTEND TO
E: LE
0
)W
CA!Il I AM THE W OFD D DISCONNECT PLUG AND
Es B04E DESCR L,0ROPE TY.
ABANDON HOUSE SEWER
i G N A0O,sl
R
D �B; 'ORES, W A ROPER
N NT
IAL,.
OF PER MrTTEEBACKFILLS
POOLS Tj'
VALIDATION JACK R. ALLEN
CK. M.O. CASH
SUPERVISING MECHANICAL ENGINEER
9 0149'-�su j.
COUNTY OF LOS ANGELES TEMPLE CITY # 0508 SEWER PERMIT
DEPARTMENT OF PUBLIC WORKS 9701 LAS TUNAS BE 0508 0904160001
BUILDING AND SAFETY / LAND DEVELOPMENT TEMPLE CITY CA 91780
PHONE: (626) 285-0488 EXT:
ILEGAL ID: ISETIER / SEPTIC: SEWER I BUILDING ADDRESS: I
1 ON FILE (EXIST OCC GRP: 6448 OAK AV I
1BLDGS. NOW ON LOT: TEMP CA 917801337
(ASSESSOR INFORMATION NUMBER: (CONNECTION TYPE: I NEAREST CROSS STREET: LONGDEN I
15382-014-029 (ORIGINATION: I THOMAS PAGE: 596 GRID: J1 LOCALITY: TEMPLE CITY, Cl
(LENGTH ML TO PL: STATION: DEPTH:
[ [
TENANT: MANHOLE REFERENCE: UPPER/LOWER: TISSUED ON: PROCESSED BY: EXPIRES ON: [
04/16/09 SR 10/13/09 I
I ICOUNTY IMPROVEMENT NUMBER: I I
(OWNER: TEL. NO: IPLAN CHECK NUMBER: FI DATE FINAL BY: CODE:
[WEN HUA CHID (626) 574-6861- IJOB NUMBER: 1 3 �/A [
6448 OAK AV ITRUNK PERMIT NUMBER: (��j ��(( �1-
ITEMP 917801337 IROAD PERMIT NUMBER: (DESCRIPTION OF WORK
[AFFADAVIT: NO ICONNECT 2ND: UNIT TO PUBLIC SEWER [
IWAIVER: NO I 1
(APPLICANT: TEL. NO: (EASEMENT: NO I
IWALLACE FU (626) 279-7971- I I 1
14424 SANTA ANITA 205 [RECORD INSTRUMENT NBR: RECORD DATE: ISPECIAL CONDITIONS: 1
[EL MONTE, CA 91731 HIGHWAY/STREET WIDENING: 1 1
[ ISTATE ENCROACHMENT PERMIT NUMBER: 1 I
ICONTRACTOR: TEL. NO: 1 FEES PAID (APPROVALS DATE INSPECTOR SIGNATURE 1
ICHIU, WENHUA (626) 574-6861- 1 1 1
16448 OAK AVENUE LIC. NO IFEE DESCRIPTION: QUANTITY: DOM: AMOUNT:INEW HOUSE SEWER
ITEMPLE CITY, CA 91780 799540 1 1 1 1
1 101 PERMIT ISSUANCE FEE 27.75 CONNECT ADDITIONAL I 1 1
1 103 CONN TO PUBLIC SEWER 1.00 CON 46.95 BUILDING OR WORK I 1 1
(ARCHITECT OR ENGINEER: TEL. NO: I TOTAL FEES 74.70 I I I
IWYF ARCHITECTURE (626) 279-7971- I ISEPTIC TANK, SEEPAGE PITI I I
14424 SANTA ANITA AVE STE 205 LIC. NO: 1 (AND/OR DRAIN FIELD I I
1EL MONTE CA 91731 C26061 1 1DRYWELL
1 SEWER MAP BOOK: PAGE: 1 [ALTER, REPAIR, SEWER OR I 1 1
SEWAGE DISPOSAL SYSTEM I
L IDISCONNECT PLUG AND 1 1
I �j p jiS(4�G 1 ABANDON HOUSE SEWER I 1
[BACKFILL SEPTIC TANKS _1 1
1 1 ISEEP. PIT _ CESSPOOL _1 1
I I 1GRAYWATER SYSTEM 1 I
I I I al I I
I I I I I I
1 1 1 I I I
I I 1 I I 1
I I I I i I
I I I I 1 I
I I I I I I
IREPORT ID: DPR266 ROUTE TO BS0508 I I
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