HomeMy Public PortalAbout5565 SANTA ANITA AVE_Sewer__ Job A-211
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6A6420 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 � T -------
WILLIAM A. JENSEN, Supt of Building LOCALATY TempleCity—
FOR APPLICANT TO FILL IN
-LE-GAL
_DESCRIPTION LOT NO. OWNER e
A
MAIL
BLOCK 'TRACY ADORE
ss_
NO. OF BLD GS. F,
_Srz.E_OF LOT NOW ON LOT CITY LU) y TEL. NO.
U5E OF
BUILD 1 I'l r-SDISTRICT NO,j GROUP MAP PC PROCESSED BY
BK
A
CONTRACTOR _5
ADDRESSCONNECTION DATA
CITY El� ` onte TEL. NO. 444-1559 STATION DEPTH
STATE UPPER
MANHOL.E REFERENCE
_fE?
_j_�_TRATION NO. COUNTYOWER'
NO. 1 IYE_S�CRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L.
PUBLIC SEWER $5.00
P.C.NO, 0-
SEPTIC TANK,SEEPAGE PIT OR CO, IMP. NO. JOB NO. 0
P I T S AND,, @ sio.00_j_____1
-.,,_--.--_?RDRAINFIELD__
HOUSE SEWERCONNECTINGTO
TRUNK PERMIT NO. ROAD PERMIT NO.
PRIVATE DISPOSAL SYSTEM @ $3.00
0
0. ATE
WORK
N
ADDITIO AL BLDG.OR
TO HOUSE SEWER @ $3.00
EXTN.,CESSPOOL,DRYWELL.MANHOLE@ S5.00
HWY.OR ST.WIDENING
t ALr ER.RE I R OR ABANDON HOUSE - -�
_,5L � 7–
11WER O�DI S�STEM @ 3 a.rao
PERMIT NO.
WASTE APPROVAL
OWNER'S PERMIT E 2�; 00 CHARGES-__
CONNECTION CHARGE FEE
AUTHORIZATION] TOTAL FEE
1]0
00
0
't HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTORTO CONNECT CT THE ABOVE
DESCRIBED EXISTING DWELLING
TO
T, Pt:,Sl.IC SEW OS
1E FR. APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS—DAY OF-1 9— 1,77-
OWNER OR NEW HOUSE SEWER
OWNERS AGENT—____ CONNECT ADDITION- AE
ADDRESS BUILDING OR WORK
SEPTIC TANK....... .
I 1HP..RF5Y ACKNOWLEDGE THAI' I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
ANDSTATE THAT THE. ABOVE IS CORRECT AND AGREE To COMPLY
WITH ALL COUNTYORDINANCES AND STATE LAWS REGULATING
PL-1 ME3 ING AND SEWERS. CESSPOOL ❑ DRYWELL
1HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LK"ENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF 'SWAGE DISPOSAL SYSTEM
ALIFOPNIA OR THAT I AM THE LEGAL OW.N.ER OF, AND,01JOEND TO DISCONNECT PLUS AND_____�__
RESIDE IN, THr ',��VE y-, AVANDON HOUSE SEWER
SrGNAtURE '
OF PERM I TTE BACKFILL SEPTIC TANKS
SEEP,PITS) CI CESSPOOLS
�.---VALIDATION ROBERT A. WOOD
6K.- M.0. CASH SUPERVISING MECi-iANICAL ENGINEER