HomeMy Public PortalAbout5447 TEMPLE CITY BLVD_Sewer__ 9
a&e66 lan APPLICATION FOR PERMIT 1
DVMON OF BUILDING AND SAFM SEWER—SEWAGE DISPOSAL
D"artuamt of Comity Enghum
COOnty of TAS Ange10B FS
LDING
JOHN A LAMBIE COUNTY ENGINEER RESSCASSATT D GRIFFIN SUP T or BUILDING ALITY
FOR APPLICANT TO FILL IN eposs"s sr
LEGAL OWNER ,
DESCRIPTION WT NO
Q1 0 MAIL
BLOCK' TRACT / OL/ ADORE59 v
/ NO OF BLDGS CITY TEL NO
SIZE OF LOT NON ON LOT �.
USE OF
BUILDINGS DISTRICT NO GROUP YAP
S = p PG
CONTRACT00. f2
ADDRESSONNECTION DATAirw
'
CIT TEL NO / STATI01 DEPTH
O MANHOLE REFERENCE UPPER-
REGISTRATION NOE
6 lz � COUNTY
No DESCRIPTION OF WORK FEE
ROUSE SEWER CONNECTING TO TYPE OF CONNECTION P LENGTH FROM /
PUBLIC SEWER Q $S SO Y L TOP L D
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD ® 33 00
IXTTHRF CESSPOOL DRYWELL.MANHIOLE S Z 00 CO IVP NO Io2. 6aZ JOB NOO
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM ® $I 00 PERMIT NO ROAD PE O
CONNECT ADDITIONAL BLDG OR STATE ENC
WORK TO HOUSE SEWER ® S 100 PERMIT NO
ALTER REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM ® $100 WASTE APPROVA '
CHARGES
4ECTION CHARGE FEE
OWNER'S Pam s 1 00
AUTHORFLATION TOTAL FEE REIYBURSEYENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON APPROVALS DATE INS ECTOR SSIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED IXIlTIXG DWELLING
TO THE PUBLIC SEWER` , NEW HOUSE SEWER
SIGNED THIS x/T DAY OF 9 CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK
OWNERS AGENT SEPTIC TAN K,SEEP,PIT(S)
ADDRESS AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HA 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 SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
IHEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AMD/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AY THE LEGAL OWN OF THE ABOVE
DESCRIBED RESIDENTIAL-kROPARTY BACKFILL SEPTIC TANKS
SIGNATURE ' SEEP PIT(!) ❑ CESSPOOL! I
OF PERMITTEE
JOHN A LAMBI . COUNTY ENGINEERVALIDATION ROBERT A WOOD CHIEF PLBG INSPECTOR
( ■ 0 GKN
XD1884A .M 16 4 450 P