HomeMy Public PortalAbout5749 TEMPLE CITY BLVD_Sewer__ D
5&E-6S3 IP•S5 APPLICATION FOR PERMIT 1
3 Bc -S
DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Department of County Engineer
County of Los Angeles BUILDIN
JOHN A. L AMBIE, COUNTY ENGINEER AD4RESS,
CASSATT D.GRIFFIN, SUPT OF BUILDING LOCALITA
NEAREST
_ OR APPLICANT TO FILL IN _ _CROSS ST.
LEGAL r
pESCRIPTION LOT NO ✓ t^ :-`�t��3 'G F. ` GWNE_R a�" dz'="
MAIL
BLOCK TRACT f'-. ---------- --ADDRESS
„9t-0_SDF BL4GS. – _._---. r
SIZE OF LOT - rJ ,r .NOW ON LOT CITY s.yx � s _EL. NA. ✓saaL% .
USE OF ��"�
BU6LDINGSi 'SI'ad'•ze�:r DISTRICT NO. GROUP. MAP
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CONTRACTOR y _ g4..,•'f ..-+��' -' •, ;•"q,,,. I, - "'
CONNECTION DATA
ADDRESS `
STATION _ _–j DEPTH
CITY TEL.NO. OY; dyt MANHOLE REFERENCE
STATE -, ,3 `
6yy t,. �:_ ❑ ---._.__._----------- .. —
REGISTRATION NO, p � ❑ COUNTY
NO. 1 DESCRIPTION OF WORK YEE _.----.— - — ------- -- ---
HOUSE SEWER CONNhC71NG TO ----- ,...� i LENTH FROM
Y TYPE OF U 7IONP.L. M.LGTO P.L.
PUBLIC SEWER @Tu $3,50
---� SEPTIC TANK SEEPAGE PIT OR - ----^ –_.-- –T--
PlTS AND/OR llR_AINFIEL_D fry$3.00:
I OVERFLOW SEEPAGE PIT, DRAINFIELD P. C. NO,
XTN.,CESSPOOL,DRYNELL,MANHOLE Q $2.001 ----- CO. IMP. NO. 'JOB NO.
E — —�—
_ I
PRIVATE DISPOSAL SYSTEM _ a, 1 I TRUNK PERMIT NO. ROA4P_E_R_MST'NO.
— — HOUS..SEV�'ER CONNECTING T3 Y � —, -
I.00 _
CONNECT vD DITIOP AL BLDG OR
STATE ENCROACHMENT
WORK TO HOUSE SEVOER - (*�; $I.00 I _ PERMIT NO.
ALTER,REPAIR OR ABANDON HOUSE I -
OR DISPOSAL SY5IEM cal $I.00 INDUSTRIAL
_— i -- I WASTE APPROVAL -
( —
CHARGES
-------_-----._)__ __ CONNECTION CHARGE FEE
OWNER'S PERr.'IIT - $ 1 00
REIMBURSEMENT FEE
AUTI'dORIZA'TICZN TOTAL FEE --�- 1-� s7
APPROVALS DATErldsPEcroR'sslGNATtRE
I HAVE f.T' THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- I
ITRACTOR Tj : Ci'NECT THE ABOVE DESCRIBED EXISTING DWELLING
7'0 THE PUB11C WER. : � ,r� � - NEW I90U5E SEWER
SIGNED TH1 DAY OF `� _.19 ` -} --
CONNECT ADDITIONAL
OWNER OR A BUILDING OR WORK
OWNERS
—.. —��..
NIRS AGENT "_ :�. 4.rT_._ SEPTIC TANK,SEEP, PIT(S) ! -- I{ ---s----
.ADDRESS X� __.1.._€LfD'_> -.� .. AND,'4R UR i*_LD ._.
I HEREET .ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL L-I
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY ----_..-_-��------_-
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLU N,.EING ;AND SEWEP.S. SEWAGE DISPOSAL SYSTEM
FLRCb''! CERTIFY 'I H.A7 ! AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND j
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF -
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE A BANDON HOUSE SEWER -
DESCRIBED RESIDENTIAL PROPERTY, BACKFILL SEP-FIC TANKS El
SEEP. PIT(S) J CESSPOOLS Lt
SIGNATURE _�_-----=—
OF PERMITTEE
i
JOHN A. LAMBIE,COUNTY ENGINEER VALIDATIOX ROBERT A.WOOD, C!'IIEF'PLBG. INSPECTOR
CK. N.U_ CASH) -