HomeMy Public PortalAbout5728 A-E TEMPLE CITY BLVD_Sewer__ L
S&a4311ES APPLICATION FOR PERMIT 1
DIVISION OF BUMDING AND SAFETY " SEWER-SEWAGE DISPOSAL
- D"airtment of County Eno'ewr :
County 0f Los Angel" 'BUILDING �
JOHN A LAMBIE COUNTY ENGINEER ADDRESS
m C:ASSATT D GRIFFIN $UP T OF BUILDING LOCALITY
FOR APPLICANT TO FILL IN NCRROOs""e sT
LEGAL / /
DESCRIPTION LOT NO r OWNER
MAIL
BLOCK. TRACT '-^ ' ADDRESS
MO OF BLDG$ • _ TEl NO ^
SIZE OF LOTy NOW ON LOT
USE
BUILDINGS DDISTRICT NO GROUP YAP
7' BE PG
CONTRACTOR ,
• CONNECTION DATA
ADDRES 1
TEL NO
3 STATION 7 DEPTH
MANHOLE REFERENCE _ L0
[STATE L .7
MER
REGISTRATION PO 3 3 ❑ COUNTY If
No DESCRIPTION OF WORK FEE
ROUSE SEWER CONNECTING TO TMP[OF CONNECTIO L Y L TOP L LENGTH L ,
PUBLIC SEWER 0 S 3 SO Y CURB P
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD ® S S 00
OVERFLOW SEEPAGE PIT GRAINFIELD P C NO
EXTN CESSPOOL,DRYWELL MANHOLE® $2 00 CO IMP NO 309 NO
"OUSE SEWER CONNECTING TO _
PRIVATE DISPOSAL SYSTEM (a $100 TRUNK PERMIT NO ROAD PERMIT NO
CONNECT ADDITIONAL BLDG OR O STATE ENCROACHMENT r
WORK TO HOUSE SEWER ® $100 PERMIT NO '
ALTER REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWEROR DISPOSAL SYSTEM- 6100 WASTE APPROVAL
CONNECTION CHARGE
OWNER'S FEErrm S 1 00 R6IYBUR4 YENT F �
AUTHORTEATION TOTAL FEE Q p
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED COM APPROVALS DATE N 4NSPP=OR SSIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER NEW HOUSE SEWER '1
SIGNED THIS DAY 19_ CONNECT ADDITIONAL
OWNER OR 1 BUILDING OR WORK _
OWNERS AGM SEPTIC TA NK,SEEP PIT($)
ADDRESS AND/OR GRAINFIELD _
I "
ACKNOWLEDGE THA HAVE READ THIS APPLICATION CESSPOOL❑ ORYWELL❑
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
I HEREBY CERTIFY THAT I AY PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND '
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT AM TH LEGAL OWNE F THE ABOVE
DESCRIBED REND NTI ROP BACKFILL SEPTIC TANKS❑ '
SIGNATURE SEEP PIT(S) [01 CESSPOOLS
OF PERMITTEE - -
JOHN A LAMBIE COUNTY ENGINEER VALIDATION ROBERT A WOOD CHIEF PLBO INSPECTOR ,
_ - I.1ID:4 3V7ZR X23_ 4 5.50. 1D
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