HomeMy Public PortalAbout4505 TEMPLE CITY BLVD_Sewer__ aa9Gas Ilan APPLICATION FOR PERMIT 1
DIVISION OF BUMDING AND SAFETY SEWER—SEWAGE DISPOSAL
D%xwbnsut of County Eugtnesr
County of Los Angels 7L �
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JOHN LAMBIE COUNTY ENGINEER
m CASSATT D GRIFFIN SUP T OF BUI=IKG
FOR APPLICANT TO
LEGAL DESCRIPTION LOT NO
BLOCK TRACT
ADORES! '
i BL063 CITY TEL NO
SIZE OF L N LOT
USE OF
BUILDINGS YAP
DISTRICT NO GROUP
BK P6
CONTRACTOR 14
ADDRESS
CONNECT! DATA
I
STATION DEPTH
CITY TEL x
MANHOLE REFERENCE
REGISTRATION NO (/ O ❑ COUNTY LOWER I/
NO DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO TYPE OF ECTION LENGTH FROM /
PUBLIC SEWER @ S 3 SOtL Y P L M L TO P L
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD @ $3 00
OVERFLOW SEEPAGE PIT DRAINFIELD P C NO
EKTN CESSPOOL,DRYW ELL MANHOLE ® $2 00 CO IVP NO JOB NO
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM a $1 00 TRUNK PERMIT NO ROAD PERMIT NO
CON N ECT ADDITIONAL BLDG OR STATE ENCROACHMENT
WORK TO HOUSE SEWER ® $100 PERMIT NO
ALTER REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM
® 100 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE _
OWNERS PERMIT s 1 00
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- APPROVALSbATf I INJfECTOR SSIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EKISTING DWELLING I (
TO THE PUBLIC SEWER NEW HOUSE SEWER
SIGNED THIS DAY Op 19_ CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK-
OWNERS AGENT SEPTICTANK SEEP PIT($)
ADDRESS AND/OR DRAINFIELO
I HEREBY ACKNOWLEDGE THAT 1 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 1 AY PROPERLY REGISTERED AND/OR pISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS NGELES COUNTY 0 STATE OF ABANDON CT PLUGHOUSE AND
CALIFORNIA OR THATWER
M T LEGAL OW R TN BOYE
DESCRIBED RESIDENTI OP BACKFILL SEPTIC TANKS❑
SIGNATURE / /
SEEP PIT(S) ❑ CESSPOOLS O
OF PERYITTE
JOHN A L IE CCUfjfY ENGINEER VAIMATIO ROBERT A WOOD CHIEF PLBG INSPECTOR
CK f,&9CASH/ �s22 4 450 to