HomeMy Public PortalAbout4950 TEMPLE CITY BLVD_Sewer__ e nc ees 11 ee APPLICATION FOR PERMIT
DrMON OF MUDING AND SAFETY SEWER—SEWAGE DISPOSAL 1
DerorlumpW of County Englnase
County of Los Angeles OUILDINO
JOHN A LAMBIE COUNTY ENGINEER ADDRESS
m CASSATTD GRIFFIN SUPTOFBu1LDINO LOCALITY
EAREIT
FOR APPLICANT TO FILL IN CROSS ST
LEGALOIINER
DESCRIPTION LOT NO
MAIL
BLOCK TRACT ADDRESS
NO OF BLq CITY TEL NO
312E OF LOT NOW ON LOTT CrL�
USE OF DISTRICT NO GROUP MAP
BUILDINGS
s
BR PG
CONTRACTOR
ADDRESS CONNECTION DATA
CI TEL NO STATION DEPTH
MANHOLE REF R CE UPPER ,
STATE LOWER
REGISTRATION NO JA COUNTY
No DESCRI TION OF WORK FEE
HOUSE SEWER CONNECTING TOTYPE CONNECTION LENGTH FROM
PUBLIC SEWER @ S 3 SO Y URB P Y L TO P L
SEPTIC TANK SEEPAGE PIT OR
PITS AND/OR DRAINFIELO 0 $3 00
OVERFLOW SEEPAGE PIT DRAIXFIELD P C NO
EXTN CESSPOOL DRYWELL MAN XO LE 0 f 1 OD CO IMP NO JOB NO
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM ® $I GO TRUNK PERMIT N91 ROAD PERMIT NO
CONNECT ADDITIO NAL BLDG OR STATE ENCROAC ENT
WORK TO ROUSE SEWER ® f 100 PERMIT NO
ALTER,REPAIR-6061MM"N HOUSE INDUSTRIAL
SEWER OR DLttOeKYyVeTEY 100 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNER'S PEOUT s t DO
AUTHORMTION TOTAL FEE REIMBURSEMENT FEE
1 HAVE AT1�HIS DATE A CONTRACT WITH THE HEREIN YED CON APPROVALS DATE INSPECTOR SSIGNATURE
TRACTOR Td'COHNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER NEW HOUSE SEWER
SIGNED THIS DAY OF 9— CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK
OWNERS ABEKT SERIC TANK SEEP,PIT(S)
ADDRES ANO/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE PEA XIS APPLICATION CE99POOL❑ DRYW[LL❑
AND STATE THAT THE ABOVE IS CORRECT AX AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR,B OR
PLUMBING AND SEWERS
1 He
CERTIFY THAT 1 AN PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON ROUSE SEWER
CALIFON NIA OR THAT I AY THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIAL PROPERTY BACKFILL SEPTIC TANKS❑
SIGNATURE
� ����" SEEP PITS) CESSPOOLS❑
OF PERXITTE6 cv _
JOHN A LAMIBIE COUNTY ENGINEER VALIDATION ROBERT A WOOD CHIEF PLBG INSPECTOR
CK* Y G
` : M 2 4 4 7In SEP 19 4 3.00 9