HomeMy Public PortalAbout5616 TEMPLE CITY BLVD_Sewer__ ::agas ll ee APPLICATION FOR PERMIT
DIVffiION OF RUIIZING AND SA= SEWER-SEWAGE DISPOSAL
Dopm tont of County Engineer
County of Los Angeles
BUILDING
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JOHN A LAMBIE COUNTY ENGINEER AGGRESS
® CASSATT D GRIFFIN SUP T OF BUILDING LOCALITY
FOR APPLICANT TO FILL IN CROS BT t z DA.v
DESCRIPTION LOT No OWNER
/ PAIL l
BLOCK TRACTM/.S�/O/J Vi'PW P AI ADDRESS o7 Co �4 (�
SIZE OF LO }3- ( NOWOON LOTLOGS CITY l TEL NO Oy�
USE DISTRICT NO GROUP YAP
SEOFBUILDINGS
CONTRACTOR A �' BK _ P°
ADDRESS �Z CONNECTION DATA Cr
CITY { TEL NO STATION Z DEPTH
MANHOLE REFERENCE . UP
REGISTRATION NO Q..GPATE WER
l LlCOUNTY ,
NO DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO TYPE OF CONNE ON LENGTH FROM
PUBLIC SEWER S!SO (� Y CURB P L Y L TOP L
SEPTIC TANK SEEPAGE PIT OR
PITS AND/OR GRAINFIELD ® S 3 00
OVERFLOW SEEPAGE PIT GRAINFIELD CO IMP NO I JOB NO
EXTN CESSPOOL DRYWELL MANHOLE ® 32 00
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM ® S 1 00 TRUNK PERMIT NO ROAD PERMIT NO
CONN ECT ADDITIONAL BLDG ORJABOVE
STATH ENCROACHMENT
WORK TO HOUSE SEWER ® S 1Q U PERMIT NO
ALTER,REPAIR OR ABANDON HOUSEINDUSTRIAL
SEWER OR DISPOSAL SYSTEM I@ 100WASTE APPROVAL
CHARGE!
CONNECTION CHARGE FEE
OWNER'S PEBbIIT I o0
AUTHORIZATION TOTAL FEFREIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEAMED CON APPROVALS _ DATE INSP GN URE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EDWELLING Lool
TO THE PUBLIC SEWER NEW HOUSE SEWER
SIGNED THIS DAY IB_ CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK
OWNERS
AS
SEPTIC TANK SEEP,PIT(S)
ADDRES ANO/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THA 1 HAVE D PLICATION CESSPOOL❑ DRTW ELL❑
AND STATE THAT THE ABOVE IS CORRECT AND O COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LEGULATING ALTER,REPAIR SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT 1 AY PROPERLY RED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES UNSTATE OF
CALIFORNIA OR THAT 1 THE LEGAL Al ERHE ABOVE ABANDON HOUSE SEWER
DESCRIBED RESIDENTIAL PERTY , BACKFILLSEPTICTANKS❑
SIGNATURE SKEP PIT(S)
❑ CESSPOOLS I] ,
OF PER ITTE
JOHN A LAMBIE,Co TY ENGINEER � ALIDATION ROBERT A WOOD CHIEF PLBG INSPECTOR
M295 APR15 4 A 550 91