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HomeMy Public PortalAbout5746-5748 TEMPLE CITY BLVD_Sewer__ CE8086.60 APPLICATION FFR PERMIT 78A642D COUNTY OF LOS ANGELES SEWER--SEWAGiE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION BUILDING I0I3N A. LAMBIE. County Engineer ADDRESS 4 WILLIAM A. JENSEN, Sup't of Building LOCALITY NEAREST FOR APPLICANT' TO FILL IN CROSS ST, � LEGAL F*^ho :-a DESCRIPTION LOT NO.. �'.+' f OWNER - aj ' BLOCK TRACT MAIL l ADDRESS NO.OF SLOGS. SIZE OF LOT NOW ON LOT CITY TEL. NO. UI BLDINGS DISTRICT NO. GROUP MAP PROCESSED BY UI BIS $G -- CONTRACTOR 1' ADDRESSCONNECTION DATA CITY y r/_. - ..`_ TEL STATION DEPTH - © STATE MANHOLE REFERENCE UPPER REGISTRATION NO. ❑ COUNTY LOWER NO. I DESCSNPTION OF WORK FEE r, HOUSE SE 'R CONNECTING TO .- d„ � ✓� . PUBLIC SEWER td $3.00 TYPE OF CONNECTION LENGTH FROM SEPTIC TANK.,SEEPAGE PIT OR Y. CUR$ P.L. M.L.TO P.L. P1T_S AND/OR DRAINFIELD $3,00 - OVERFLOW SEEPAGE PTT, DRAINFIELD EXTN..CESSPOOL, DRY`WELL @ $2.00 HOUSE SEWLR CONNECTING TO P.C.NO. PRIVATE DISPOSAL SYSTEM @ $1.00 CO.IMP, NO, JOB NO, 104. CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT NO, O WORK TO HOUSE SEWER C�? 51.00 0 A RFPAIR4 x,�� STATE ENCROACHMENT w S`WER @ $1.00 I �' PERMITNO. O H INDUSTRIAL C) WASTE APPROVAL CHARGES O INERIS PERMIT S 2 00 CONNECTION CHARGE FEE AUTHORIZATION I TOTAL FEE " I -0 REIMBURSEMENT FEE I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE TO THE PUBLIC SEWER. SIGNED THIS DAY OF 19— NEW HOUSE SEWER OWNER OR CONNECT ADDITIONAL OWNERS AGENT BUILDING OR WORK ADDRESS— SEPTIC TANK,SEEP.PIT($) ----- AND/OR DRAINFIELD I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION. AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPO0;_ !` DRYWELL ❑ WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING .PLUMBING AND SEWERS —ALTER-REPAIR,SEWER SEWAGE u 'GSAL SYSTEM I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND LICENSED AS REQUIRED By-LOS ANGELES COUNTY AND STATE OF ABANDON CT PLUG CALIFORNIA Or THAT I,°A M`'THE LEGAL OWNER OF THE ABOVE DESCRIBED RESIDENT L/-PROPERTY ^''✓ BACKFPIT(S)P❑ CESSPOOLS❑LS SIGNATURE OF PERMIT? ✓ L= 1 � .`- S `' ---VALIDATION ROBERT A. WOOD cx. j M.0. CASH SUPERVISING MECHANICAL ENGINEER