HomeMy Public PortalAbout5636 TEMPLE CITY BLVD_Sewer__ TiAe41D •
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DIVISION OF BUILDBiG ACSgFp'j, 'yI O NPERMIT
SEW RSEWGE DISPOSAL 1
Dopar neW of Couafy Engiawe
County of Lw Ango1Me Bu1LDlnc
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JOHN A LAMBIE COUNTY ENGINEER
ADDREB!
m _ CASSATTD GRIFFIN SUPTOPBUILDING LOCALITY
FOR APPIJCANT TO FILL IN RLA EST
S ST
LEGAL OWNER
DESCRIPTION LOT NO
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All. It
BLOCK TRACT KESS
OF BL -S ,CITY _ TEL NO
912E OF LOT OW ON LOT
USE OF
BUILDING! DISTRICT NO GROUP YAP
B� PG
CONTRACTOR .i
ADDRESS AAQV CONNECTION DASA
CITY TEL O
STATION DEPTH
Ly N
MANHOLE REFERENCE A UPPQR
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REGISTRATION NO COUNTY
NO DESCRIPTION OF WORIlt FEE
ROUSE SEWER CONNECTING TO TYPE OF CONNECTION LENGTH FROM
PUBLIC SEWER Q S 9 90 - CURB P L M L TO P L
SEPTIC TANK SEEPAGE PIT OR ,
PITS AND/OR DRAINFIELD ® 33 00
OVERFLOW SEEPAGE PIT DRAINFIELD P C NO
EXTN CESSPOOL DRYWELL MANHOLE ® S r 00 CO IMP NO JOB NO
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM ® $1 00 TRUNK PERMIT NO - ROAD PERMIT NO
CON N ECT ADDITIONAL SLOG OR STATE ENCROACHMENT
WORK TO HOUSE SEWER ® S 1 00 PERMIT NO
ALTER REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM ® S 1 00 - WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNER'S PERbD7 $ 1 00
AUTFIORIZATION TOTAL FEE REIMBURSEMENT FEE -
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAYEO CON- APPROVALS PATE INSP CTOR SSIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER NEW HOUSE SEWER I1
SIGNED THIS DAY OF 19_ CONNECT ADDITIONAL
OWNER OR . BUILDING OR WORK
OWNERS AGENT SEPTIC TANK SEEP PIT(9)
ADDRESS AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOLO 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 1 AY PROPERLY REGIST EO AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS GELES COUNTY D ST E OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT T LEGAL OWNS THE, OVE
DESCRIBED RE9IDEN PE BACKFILL SEPTIC TANKS
SIGNATURE SEEP PIT(S) ❑ CESSPOOL!❑
DF PERMITTEE
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JOHN A LA IECOUNTNIENGINEER VALIDATION ROBERT A WOOD CHIEF PLEIG INSPECTOR
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