HomeMy Public PortalAbout5619-5619 1/2-5621-5621 1/2 TEMPLE CITY BLVD_Sewer__ Ito APPLICATION FOR PERMITJa" s";;k1
DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL
Department of County Engha
County of Im AngeleseUILDIn 512
JOHN A LAMBIE COUNTY ENGINEER ADDREss �L
m CASSATT D GRIFFIN SUP T OF BUILDINat
LOCAL
FOR APPLICANT TO FILL IN CROSS QST
LEGAL
DESCRIPTION LOT NO /�?L OWNER
MAIL
BLOCK TRACTn t01� ADDRESS :17
SIZE OF LOT %L/ NOW ON LOTS CITY l TEL NO
USE OF DISTRICT NO GROUP YAP
CONTRACTOR �K P
/ y
ADDRESS4�1 ///��1 V CONNECTION DATA
CITY TEL NO T STATIOR -+ O DEPTH
MANHOLE REFERENCE
JT ❑ STATE LOWE
REGISTRATION NO 11A(./ ❑ COUNTif
No DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO TYPE OF CONNECTION LENGTH ;ROY
PUBLIC SEWER Q CURB P L Y L TOP L
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD ® $3 00
OVERFLOW SEEPAGE PIT DRAINFIELD P C NO
EXTN CESSPOOL DRYWELL MANHOLE ® S 2 00 CO IMP NO JOB NO
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM ® $1 00 TRUNK PERMIT NO ROAD PERMIT NO q*3 -345F7
CON N ECT ADDITIONAL BLDG OR STATE ENCROACHMENT
WORK TO HOUSE SEWER ® S 1 00 PERMIT NO
ALTER REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM Q $1 00 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNERS PERMIT S 00
AUTHORIZATION TOTAL FEE
REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON' APPROVALS DATE INSPECTOR SSIGNATURE
TRACTOR TO CONNECT THE ABOVE DE RIRED EXISTING DWELLING
TO THE PUBLIC SEWER NEW HOUSE SEWER
SIGNED THIS DAY OF 19 / O
CONNECT ADDITIONAL
OWNER OR / BUILDING OR WORK
OWNERS AGENT SEPTIC TANK SEEP PIT(S)
ADDRESS AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE 19 CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWEROR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY T 1 AY PROPERLY R ERED AHD/OR
LICENSED p5 REOUIR LOS ANGELES C TY AND STATE F DISCONNECT PLUG AND ,
CALIFORNIA OR TH AN THE L HER F THE AS E ABANDON HOUSE SEWER
DESCRIBED RESIDE PROPERTYBACKFILL SEPTIC TANKS[I
SIGNATURE SEEP PIT(S) El CESSPOOLS❑
OF PER
JOHN A LAMBIE NTY ENGINEER �IDA'I'IO ROBERT A WOOD CHIEF PLBG INSPECTOR
CK I Ca? U V 4,14 JAR 21 1 0 A 6.0 0 x