HomeMy Public PortalAbout5428 TEMPLE CITY BLVD_Sewer__ 70AG4,,,,BeAPPLICATION FOR PERMIT 1
DMSION'OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Depmtnant of County Engln"a
County of Los Angel" BUILDING
JOHN A LAMBIE COUNTY ENGINEER ADDRESS
® OASSATTO GRIFFIN SUPTOPBUILDINO LOCALITY
F B LICANT TO FA/LL IN CRos"BE'sTLEGAL f o WI i�
DESCRIPTION L T NO y OWNER Q�'
MAIL
BLOCK TRACT ADDRESSZ 7X ,PCG L L
NO OF SLOSS CITY TEL NO
SIZE OF LOT NOW ON LOT
USE DI fTRUNX
STRICT NO GROUP YAP
USE
BUILDINGS
BR PG
CONTRACTOR
ADDRESS D / COIRMCTTON DATA
CITY Q TEL NO / / TION SS/ 3 DEPTH
HOLEREF ENCR UPPER
STLOWER
REGISTRATION NO / 4 ❑ COO �JNo DESCRIPTION OFWO K FEEHOUSE SEWER CONNECTING TO TYPE OF CONNECTION LENGTH FROM
PUBLIC SEWER @ $3 SO CURB P L Y L TOPL
SEPTIC TANK SEEPAGE PIT OR
PITS AND/OR DRAINFIELD ® S S 00
OVERFLOW SEEPAGE PIT DRAT NFIELDP C NO
fiXTN CESSPOOL ORYWELL MANHOLE S 2 00 IMP NO JOB NO
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM ® 91 00 PERMIT NO ROAD PERMIT NO
CONNECT ADDITIONAL BLDG OR STATE ENCROACHMENT
WORK TO HOUSE SEWER S 100 ]REGULATING
PERMIT NO
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM 1 00WASTE APP AL
HARGFS
CON IE ION CHARGE FEE
OWNER'S PEDW s0
AUTHORIZATION TOTAL FEE
REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN N � �V�"g DATE INSPECTOR 98IGRA7URE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTINNG
TO THE PUBLIC SEWER NEW HOUSE SEWER •-
SIGNED THIS DAY OF CONNECT ADDITIONAL 11��
OWNER OR BUILDING OR WORK I �p
OWNERS AGENT SEPTICTANK SEEP,PIT(S)
ADDRESS AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS ON CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREELY
WITH ALL COUNTY ORDINANCES AND STATE LAWS NG ALTER,REPAIR SEWER OR
PLUMBING AND SEW0,T11
SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFYPROPERLY REGISTERLICENSED AD REQUIRNGELES C GI AOF 018COMNECT PLUG ANO
CALIFORNIA OR TNALEGAL ER VE ABANDON ROUSE SEWER
DESCRIBED RESIDENTBACSEEP FILLPIT SEPTIC
CTANKS0❑
SIGNATURE �'
OF PERMITTEE
IP
JOHN A LAMBIE COUNTY ENGINEERMMATIOw� ROBERT A WOOD CHIEF PLBG INSPECTOR
■ a
LrA0725MMAY 9 4A 2_ .00- X - _ _ _