HomeMy Public PortalAbout5630 TEMPLE CITY BLVD_Sewer__ 8a 986311 as APPLICATION FOR PERMIT 1
DIVISION OF BUILDING AND SAFM SEWER-SEWAGE DISPOSAL
DnpoRtaJnnt of County Engineer
County o1 Lw Angelos BLDING r6.30i9�CD6i P 1P
JOHN A IJAMBIE COUNTY ENGINEER ADnUIeEs4
m CASSATTD GRIFFIN HUPTOFOUILDIHO LOCALITY CIWIEST
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FOR APPLICANT TO FILL IN CROSS ST
LEGAL Z�17 a / _ OWNER Tz.r'r-S -;0-
MAIL LOT NO 'v
/Jlii►-+ ^ ' MALL
BLOCK TRACT �J C/"� ADDRE98
NO OF BLDGS CITY TEL NO
SIZE OF LOT NOW ON LOT
USE
BUILDINGS D / DISTRICT NO GROUP BR MAP
PG
CONTRACTOR
S ,
ADDRESS 4!FyF
CONNECTION DATA
STATION DEPTH
CITY S S TEL NO t MANHOLE REFERENCE / /'
tj STATE • LOWER
REGISTRATION NO ❑ COUNTY
NO DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO TYPE OF CONNECTION LENGTH FROM
PUBLIC SEWER 0 3 3 40 Y CURB P L M L TO P L
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 0 s 3 00
OVERFLOW SEEPAGE PIT DRAINFIELD - P C NO
EXTN CESSPOOL DRYWELL MANHOLE 0 S 2 00 CO IMP NO JOB NO
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 0 S 1 00 TRUNK PERMIT NO ROAD PERU IT NO
CONNECT ADDITIONAL BLDG OR STATE ENCROACHMENT
WORK TO HOUSE SEWER ® S 100 PERMIT NO
ALTER REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM
0 100 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT f 1 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 DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER NEW HOUSE SEWER
SIGNED THIS DAY OF I9_ CONNECT ADDITIONAL
OWNER_ OR `s BUILDING OR WORK
OWNERS AGENT SEPTIC TANK,SEEP, PITS)
ADDRESS AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE 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 ,
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED IAMBIOR OISCONXECT PLUG AND
LICENSED AS REQUIRED BY LOS ELES COUNTY AND ATE OF
CALIF XIA R
THA
PRO TH LEGAL GINNER T E ABOVE AACKFILBANDOHOUSE SEWER
DESC ED R IDENTIAL PROPER /)'/"/ BACKFILL SEPTIC TANKS❑
SIGN SEEP SEEP PITS) ❑ CESSPOOLS❑
OF PERU E
JOHN A LJAMBIE COUNTY ENGINEER ALIDATION ROBERT A WOOD CHIEF PLJSG INSPECTOR
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