HomeMy Public PortalAbout5313 TEMPLE CITY BLVD_Sewer__ e&leas 11 Be APPLICATION FOR PERMIT 1
DIVISION OF BUHM riG AND SAFETY SEWER-SEWAGE DISPOSAL
Departinans of County Engineer
County of Los Aagsbe BUILDING
JOHN A LAMBIE COUNTY ENGINEER ADDRESS
m CASSATT D GRIFFIN SUP Tor BUILDING LOCALITY
FOR APPLIC CROSS ST
LEGAL
DESCRIPTION LOT N� OWNER
BLOCK TRACTXg PAIL
ADDRESS
NO OF BLDGS y CITY TEL NO
SIZE OF LOT NOW ON LOT
USE
BUILDINGS DISTRICT NO GROUP YAP
B PD
CONTRACTOR
ADDRESS
CONNECTION DATA
STATION a DEPTH ,
clrY TeL xo
MANHOLE REFlRBNC UPPE
❑ STATE
REGISTRAT H NO ❑ COUNTY
NO DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO TYPE OF CONNECTION LENGTH FROM 3
PUBLIC SXWER S 3 SO D L Y L TO P L l7
SEPTIC TANKSEEPAGE PIT OR
PITS AND/OR DRAINFIELD 300
OVERFLOW SEEPAGE PIT DRAINFIELD CO IVP NO JOB NNo
O
EKTN CESSPOOL ORYWELL MANHOLE ® S Z 00
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 0 S 1 00 TRU PERMIT NO ROAD PERM;:;;O
CONNECT ADDITIONAL BLDG OR STATE EN PENT
WORK TO HOUSE SEWER S 1 00 PERMIT NO
ALTER REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM $1 00 WASTE APPROVAL
CHARGES
CONNECTI CHARGE FEE
OWNER'S PEHbD'f s t o0
AUMORPLATION TOTAL FEE REIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON APPROVALS DATE INSPE O0.SSIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EKISTING DWELLING
TO THE PUBASH � REW HOUSE SEWERSIGNED THIDAY OF ig� NNECT ADDITIONAL
OWNER OR _ BUILDING OR WORK
OWNERS AGESEPTIC TANK SEEP,PITISI
ADD- AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ TH APPLICATION CESSPOOL❑ DRTWEIL❑
AND STATE THAT THE ABOVE 11 CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR !EWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT I AY PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND '
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AN THE LEGAL OWN OF THE ABOVE
DESCRIBED RE91D PROPERTY BAC FILLPIT(5I)EPI CTANKS Ll
ESSPOOLS 1
SIGNATURE SEE ❑❑ L
OF PEAYITTE
JOHN A LAMBI COUNTY ENGINEER VALIDATION ROBERT A WOOD CHIEF PLBG INSPECTOR
u ■ o
J.Q2 2 9 sN MOV13 4 450 0