HomeMy Public PortalAbout5624-5626 TEMPLE CITY BLVD_Sewer__ aec e;11 SS- APPLICATION FOR PERMIT
DMSION OF BUMDING AND SAFETY SEWER-SEWAGE DISPOSAL
DeparizzieW of County Eeghwes
7
Cooafp of LOe J{Y"fes BUILDING,
JOHN A LAMBIE COUNTY ENGINEER ADDRESS
m CABBATT O GRIFFIN BIIP T OF CY(LOIN6 LOCALITY
FOR APPLICANT TO FILL IN NEAREST
LEGAL CROSS OWNER
DESCRIPTION LOT NO C ,C
MAIL
BLOCK TRACT ADDRESS '
NO OF BLDGS CITY TEL NO
S12E OF LOT NOW ON LOT
USE OF
BUILDINGS . DISTRICT NO GROUP YAP
BK P6
CONTRACTOR -- - i
ADDRESS C.ONNECTIO] DATA
e-17
STATION DEPTH /
LI L NO
MANHOLE REFERENC �_ UPPER
STATE
REGISTRATION NO ❑ COUNTY _
No DESCRIMM OF WORK FEE _
HOUSE SENE0.CONNECTING TO TYPE OF CONNECTION LENGTH FROM /
PUBLIC SEWER @ S 3 SO CURB P L Y L TO P L
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD Q S 3 00
OVERFLOW SEEPAGE PIT DRAINFIELD P C XO
EXTN CESSPOOL ORYWELL MANHOLE ® $E 00 CO IMP NO JOB NO
HOUSE SEWER CONNECTING TO 1 �/���
PRIVATE DISPOSAL SYSTEM ® 3 100 TRUNK PERMIT NO ROAD PERMIT NO ,
CONNECT A DDITIONAL BLDG OR STATE ENCROACHMENT
WORK TO HOUSE SEWER ® S 1 00 41 O PERMIT NO
ALTER REPAIR OR ARAN DON HOUSE INDUSTRIAL
SEVER OR DISPOSAL SYSTEM Q $100 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT s 1 00
REIMBURSEMENT FEE,
AUTHORIZATION TOTAL FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- APPROVALS DATE INSPEIAfOR SSIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER NEW HOUSE SEWER fJ
SIGNED THIS DAY OF 19— CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK
OWNERS AGENT SEPTIC TANK SEEP PIT(8)
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,SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT 1 AM PR ERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED A6 REQUIRED B A E9 COUNTY A STATE OF As HOUSE SEWE0.
CALIFORNIA OR THAT M HE GAL OWNER OF E VE
DESCRIBED RESIDENT P ER BACKFILL SEPTIC TANKS❑
SIGNATURE Y BEEP PITS) ❑ CESSPOOLS❑
OF PERMITTEE
JOHN A BIE, COUN71 ENGINE R VALIDATION ROBERT A WOOD CHIEF PLBG INSPECTOR
CK ■ 0 1 �H
LQ371,4N DEC27 4 5.50 61