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HomeMy Public PortalAbout5016 TEMPLE CITY BLVD_Sewer__ �f saan APPLICATION FOR PERMIT 1 bt-SION OF BUMDING AND SAFETY SEWER-SEWAGE DISPOSAL Dep=Wient of Cam? Engineer County of Los Angeles BUILDING JOHN A LAMBIE COUNTY ENGINEER ADDRESS O m CABBATTO GRIFFIN 5BCDGS DING LOCALITY FOR APPLICANIN "c OSS ST LEGAL DESCRIPTION LOT NO OWNER BLOCK TRACT MAIL MMAll.ADDRESS N70SIZE OF LOT NCITY TEL 11pSE OF DISTRICT NO GROUP MAP UILDINGSBK PO CONTRACTOR CONNECTION DATA STATION DEPTH CITY - MANHOLE REFERENCE UPPER ❑ STATE LOWER , REGISTRATION NO ❑ COUNTY No DESCRIPTION OF WORK FEE ROUSE SEWER CONNECTING TOTYPE OF CONNECTION LENGTH FROM PUBLIC SEWER W s 3 50 Y CURB P L Y L TO P L SEPTIC TANK SEEPAGE PIT OR PITS AND/OR GRAINFIELD e $3 00 OVERFLOW SEEPAGE PIT DRAINFIELOP C NO IXTM CESSPOOL DRYWELL YANHO LE ® $ 2 00 CO IMP NO JOB NO HOUSE SEWER CONNECTING TO PRIVATE DISPOSAL SYSTEM s 1 00 TRUNK PERMIT NO ROAD PERMIT NO I CONNECT ADDITIONAL BLDG OR �!,,� STATE ENCROACHMENT WON K TO HOUSE SEWER ® S 100 V PERM IT NO ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL SEWER OR DISPOSAL SYSTEM S 100 WASTE APPROVAL CHARGES CONNECTION CHARGE FEE OWNER'S PEILWT s t DO AUTHORMATION TOTAL EEE ds REIMBURSEMENT FEE I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- APPROVAL'S DATE INSPECTOR!SIGNATURE TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING TO THE PUBLIC SEWER NEW HOUSE SEWER SIGNED THIS DAY OF 19— CONNECT ADDITIONAL OWNER OR BUILDING OR WORK OWNERS AGENT SEPTIC TANK SEEP PIT(S) ADDRESS AMD/ON GRAINFIELD 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 AN PROPERLY REGISTERED AND OIBCONXECT PLUG AND LICENBEO A9 REQUIRED BY 08 ANGELES COUNTY AND STATE F ABANDON HOUSE SEWER CALIFORNIA OR THAT I THE L AL OWNER THE AS E DESCRIBED RESIDE AL PERTY - SEEPFPLL SEP❑ CTANKS❑U❑ SIGNATURE OF PERMITTER JOHN A LAMBIE COUNTY ENGINEER ©VALIDATION ROBERT A WOOD,CHIEF PLBG INSPECTOR ■ O CAAY C09 4 1 5n AUG 21 4 200 to