HomeMy Public PortalAbout9333 PENTLAND ST_Sewer__ ,,, TEMPLE CITY
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c � APPLICATION FOR PERMIT
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COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL i
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS
IORx A I.GRUT 8.p t Ey�udr
CARSAT! D GRIFFIN RvD 1 of BvildivQ LOCALITY
FOR APPLICANTTO FlH CROSS IN ST AAs kA a
LEGAL j y�^ t
DESCRIPTION LOT NO -
BLOCK TRACT �O MAIL
ADDRESS
NO OF BLOGS
SIZE OF LOT -J NOW OH LOT CITY TEL NO
USE OF v e
BUILDINGS C/ DISTRICT NO GROUP MAP PROC ➢BT
BK PG
CONTRACTOR Z67A lae�r5/
ADDRESS CONNECTION DATA 2
CITY L NO ION DEPTH
�+ TATE MANHOLE REFERENCE
REGISTRATION NO 7 COUNTY
ND I DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO `�
PUBLIC SEWER 1- 33 00 TYPE OF CONNECTION I LENGTH FROM
SEPTIC TANK SEEPAGE PIT OR Y CURB P L Y L P L
PITS AND OR DRAINFIELD $300
OVERFLOW SEEPAGE PIT DRAINFIELD
EKTN CESSPOOL DRYWELL S200 Ali
PRIVATE DISPOSAL SYSTESE SEWER CONNENMG TO @ SI 00 CO IMP NO JOB NO
CONNECT ADDITIONAL BLDG OR TRUNK PERMIT HO ROAD PERMIT NO
WORK TO HOUSE SEWER $I 00
ALTEER REPAIR OR ABANDON HOUSE Sion STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERNIITS 2 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED ERI ING DWEL N APPROVALS DATE INSPEC OR S919HATURE
TO THE PUBLIC
SIGNED AY O J NEW HOUSE SEWER •
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
ADDRES SEPTIC TANK SEEP FIT(S)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT'l HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL Q DRYWELL
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT i AM PROPERLY REGISTERED ND/OR DISCONNECT PLUG AHD
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STAATE OF ABANDON NOUSE SEWER
CALIFORNIA__DR THAT I AM THE LEG OWNER OF THE ABOVE
DESCRIBED IAL PROPE �. BACKFI LL SEPTIC TANKS Cl
SIGNATURE SE P PIT S/ CESSPOOLS
OF PERMITTE
®r ALIDATION ROBERT A WOOD
CL ■ o C H SUPERVISING MECHANICAL ENGINEER
LAZo2 - a2 �— SEP 121 0 D 500
t. � TEMPLE COTY
ceso APPLICATION FOR PERMIT
ceeoP a�P
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUELDING AND SAFETY DIVISION BUILDING
TORN A LANIDD; Co=ty. Enr-
ADDRESS
CASSATT D GRIFFIN Soy t of BwldinQ LOCALITY /
NEAREST
FOR APPLICANT TO FILL III cnoss sr
LEGAL
DESCRIPTION LOT NO 4 ,f OWNER
BLOCK TRACT O MAIL
ADDRESS
NO OF BLDGS
SIZE OF LOT7_? O NOW ON LOT CITY TEL NO
USE OF 17
BUILDINGS JOY e S/ d G I/ G DISTRICT HO GROUP BK MAPPG PROCESSED BY
CONTRACTOR IVO e �+t O
ADDRESS or �•J CONNECTION D TA
LI TEL NO - 07 ION DEPTH y
STATE MANHOLE REFER NC PPER 31
REGISTRATION NO S—q — COUNTY
No I DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER S 00 TYPE OF CONNECTION LENGTH FROM
SEPTIC T��{{NK SEEPAGE PIT OR Y CURB P L M L TO P L
PITS AND/OR DRAINFIELD 0 $ 00
OVERFLOW SEEPAGE PIT DRAINFIELD
EKTN CESSPOOL DRYWELL S3 00
HOUSE SEWER CONNECTING TO P C NO
PRIVATE DISPOSAL SYSTEM P $I 00 CO IMP NO JOB NO
WORK CTTO ADDITIONALOUSE LDG OR SI 00 TRUNK PERMIT HO ROAD PERMIT NO O
ALTER R REPAIR OR ABANDISPOSAL DON HOUSE $1 00 STATE ENCROACHMENT
SEWEPERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
owftR,s PERMIT CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE V?7 REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR 5516NATURE ,
TO THE PUBLIC S / 1
SIGNED THIS DAY OF S'e 912- NEW HOUSE SEWER I { ,
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK t/ lhv
ADDRES SEPTIC TANK SEEP PIT(S)
AND/OR DRAINFIELD /'I n
1HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE 19 CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL 4/ V
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM V
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDPqAl PROPERTY BACKFILLSEP IC TANKS
SIGNATURE
B P PIT 5 CESSPOOLS
OF PERMITTE mia /
Or VALIDATION ROBERT A WOOD
CL M o CASH SUPERVISING MECHANICAL ENGINEER
2
4 3 � SI}' 121 1 D 25.00 K
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