HomeMy Public PortalAbout4431 TEMPLE CITY BLVD_Sewer__ '°AB••°
■aMeeAPPLICATION FOR PERMIT
I1ON OF BUI[MING AND .SAFM SEWER-SEWAGE DISPOSAL 1
D%xwftant of County Engine County of I� An"Ies BUILDING ']
JOHN A LAMBIE, COUNTY ENGINEER _
m ADDRESS
CASSATT D'GRIFFIN SUP T On BUILDING LOCALITY
FOR APPLICANT TO FILL IN NEAREST
rig
LEGAL /�
DESCRIPTION LOT NO T .� � OWNER if
MAIL 171
BLOCK TRACT Z 2 17 ADDRESS
NO OF GLOSS CRY TEL NO
SIZE OF LOT NOW ON LOT
USE OF
BUILDINGS DISTRICT NOI GROUP YAP
BK PG
CONTRACT r
ADDRESS 1 CONNECTION DATA ,
STATION DEPTH
CITY S S • L • TEL N • ' MANHOLE REFERENCE
[I STATEEykq LOWER
REGISTRATION XOYORK ElCOUNTY I
NO DESCRIPTION OF WFEE
HOUSE SEWER CONNECTING TO TYPE OF CTION LENGTH FROM • ! /
PUBLIC SEWER Q 9 S SO Y R P L M L TO P L 7
SEPTIC TANK SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ 4 S DO
OVERFLOW SEEPAGE PIT DAI NF'ELOC No
EXTNF CESSPOOL ORYWELLR
RMANHOLE 0 S 2 00 CO IMP NO 4,VZ l 'OB NO
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM $1 00 TRUNK PERMIT NO ROAD PERMIT NO �T 7
CONECT ADDITIONAL BLDG OR STATE ENCROACHMENT
WORN
TO HOUSE SEWER ® S 1 00 • O'U PERMIT NO
ALTER REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM 1 GO WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNER'S ' PE9NII7 S 1 00
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED COM APPROVALS DATE INSPECTOR SSIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLINGI
TO THE PUBLIC SEWER NEW HOUSE SEWER
SIGNED THIS nAY OF 19— CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK
OWNERS AGENT ��' VVV SEPTIC TANK SEEP PIT(S)
ADDRESS AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWEROR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PR PERLY pEGISTERED AN /OR DISCONNECT PLUG AND
LICENSED RE IRED BY LOS LES COUNTY ND STAT OF ABANDON HOUSE SEWER
CALI FO IA OR HAT 1 AY THE GAL OWNEQ F THE OVE
DESCRIB REST ENTIAL PROPERTY /�� BACKFILL SEPTIC TANKS❑
SIGNATU / SEEP PITO) ❑ CESSPOOLS❑
OF PERM
I
I
JOHN A LAMBIE tOUNTY ENGINEER VALWATION ROBERT A WOOD CHIEF PLOD INSPECTOR
CA Y 0 CAM
1
LPILO
8 31 8 � MAY 2'0 4 5.50 '"