HomeMy Public PortalAbout5334 TEMPLE CITY BLVD_Sewer__ ieAeAeea APPLICAI ION. FOR PERMIT 1
DT ON OF BUnXIM AND SAFETY SEWER—SEWAGE DISPOSAL
Depmtnuni of County Engineer4ER
rQmnty of Los AngelesLDIAD�RESNG
JOHN A LAMBIE COUNTY ENGINE
m CASSATT D GRIFFIN Sup t of Su1LDIDo
RALITY 00
FOR APPLICANT TO FILL I
NEAREST
LEGAL
DESCRIPTION
LOT NO NER /�
BLOCK TRACT IA
RESS P.
fl0 OF G
SIZE OF LOT NOW ON LOTY C r TEL NO
USE DI ISTRICT NO GROUP MAP
BUILDINGS
BK PG
CONTRACTOR
ADDRESS
CO ON DATA
TION DEPTHCITY EL NO
HOLE REFERENCE
REGISTRATION NO yJ /(.NO DESCRIPTION OF WOR FHOUSE SEWER CONNECTINGTOTYPE OF CONNECTIO LENGTH ;ROYPUBLIC SEWER @ S 3 50 CURB P M L TOP L
SEPTIC TANK SEEPAGE PIT OR _
PITS AND/OR DRAINFIELD a $3 00
OVERFLOW SEEPAGE PIT DRAINFIELD P C NO
EKTN CESSPOOL,ORYWELL MANHOLE ® S E 00 CO IMP NO�-0 JOB NO
HOUSE SEWER CONNECTING TO '
PRIVATE DISPOSAL SYSTEM ® $1 00 TRUNK PERMIT NO ROAD PERMIT NO
CONN ECT ADDITIONAL BLDG OR STATE ENCROACHMENT
WORN TO HOUSE SEWER ® $1 00 PERU IT NO
ALTER REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM ® 1100 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNER'S PEDW s I 001.
AUTHORIZATION TOTAL FEE REIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- APPROVALS Y D E I CTOR ! MATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC/SlEW NEW HOUSE SEWER ('
SIGNED THIG ���
AT OF SV L� 19 CONNECT ADDITIONAL
OWNER OR --T— BUILT OR WORN
OWNER9 AGENT S
SEPTIC TANK,SEEP PIT(!)
ADDREl9 AMD/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ' THIS APPLICAT OM LE94POOL❑ DRYW ELL❑
AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS RE(.ULATING ALTER REPAIR SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUN AND STATE ABANDON No
SEWER -
CALIFORNIA OR THAT 1 AN THE LEGACOOF THE B E
DESCRIBED RESIDENTIAL P TY BACKFILL
AC FIL (SEP❑ CESSPOOLS O❑
SIGNATURE
OF PERMITTEE ,
JOHN A LAMBIE COUNTY EN INEER VALIDATION ROBERT A WOOD CHIEF PLBO INSPECTOR
CN Y 0
1, 0 6 9 4S JUL 26 4 5,5 0 n