HomeMy Public PortalAbout4425 TEMPLE CITY BLVD_Sewer__ S'06[6631186 APPLICATIOW FOR PERMIT 1
` DrMON OF BU=NG AND SAFETY SEWER-SEWAGE DISPOSAL
Department of Co>my Enpfaw
p C,Oppt7 of Lw AnQe]M BUILDING
WM J FOX. COUNTY ENGINMER ADORES!
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FOR APPLICANT TO FILL ENGIN;
DaolB
LEGAL
BY
DESCRIPTION LOT NO OWNER
!LOCK TRACT MAIL '
NO OF BLDGS. ADDRESS
SIZE OF LO / NOW ON LOT CITY TEL NO
USE OF
BUILDINGS 1 DISTRICT NO GROUP MAP
BK G
CONTRACTOR
ADDRESS Q C0NN6CiI0N DATA
I TEL NO STATION ,f� DEPTH0 STATE o
REGI/T TION NOrg( O [3 COUNTY MANHOLE REFERENCE LOWER
TYPE OF CONNECTION LENGTH FROM
No DESCRIPTION OF WORK FEE CURB M L To P L O
HOUSE SEWER CONNECTING TO
PUBLIC SEWER ! ! 50
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 100
CONNECT ADDITIONAL BLDG OR CO IMP NO16" JOB NO
WORK TO HOUSE SEWER 100
ALTER OR REPAIR EXISTING v,
SEWER OR DISPOSAL SYSTEM 1 00 TRUNK PERMIT NO ROAD PERMIT NO
DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT
AND/OR DISPOSAL SYSTEM 1 00 PERMIT NO
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/O0. DRAINFIELO i 00 INDUSTRIAL
CESSPOOL-DRYWELL -- WASTE APPROVAL
SPECIAL CONDITIONS ONLY 1 DO CHARGES
OWNEWS pmDw s t CONNECTION CHARGE FEE
AUTHOBTLATION iOTAL FEE `� REIMBURSEMENT FEE
I HAVE TRACTOHIS DATE R TOCTED ABOVEBE WITH THEHEREIN
N6AMED DWELLIOH
ORTO COMNEAPPROVALS DATE 1 SPECTOR 991GMATURE
TO THE PUBLIC
SIGNED THI AY OF — NEW HOUSE!EWER S _
OWNER OR" CONNECT ADDITIONAL
OWNERS AG BUILDING OR WORK
ADDRESS - Y SEPTIC TAHK,SEEP, PIT(G) -
ANO/OR DMIX FI ELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ TH19 APF ATION CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE 19 CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER, REPAIR,SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT 1 AY PROPERLY REGISTERED AND/OR
LICENSED AS REOUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE ABANDON HOUSE SEWER -
DESCRIBED RESIDENTIAL PROPERTY BACKFILL SE C TANKS❑ 1
BEEF PRE CESSPOOLS S
SIGNATURE
OF PERMITTE
WILLIAM J FOX.COUNTY ENGINEIm VALIDATION - -
-SAO 450
9 91,;M EBI 1. 4 4,5
O[PUT7 r IDEPUTY
S BY .r BY F� � j�
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