HomeMy Public PortalAbout5753 TEMPLE CITY BLVD_Sewer__ 666420 " APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
TOIIbI A, LRMBI£, CaeaatY Eaeyya�e®a ADDRESS
WILLIAM A. JENSEN. Sup t of$u$mg
_ LOCALITY
FOR APPLICANT TO FILL IN
NEAREST. 3BY
LEGALMAIL
DESCRIPTION LOT NO e o-6 -% e OWNER '„$LOCIf. TRACT ADDRESS}iO.OF BLDGS.S%ZE OF 16T NOWONLOTCITY TE NflUSE OFDISTRICT NO. GROUP HAP P
BUILDINGS
$K P6
01
CONTRACTOR
ADDRESS _ CONNECTION DATA
CITYy Fe 1PEL.N0. ` ' .. STATION l DEPTH
r STATE MANHOLE REFERENCE �<. PPER
REGISTRATIOIf N0. �' �. COUNTY
No [1ESCRIPTIDI°I OF WORK FEE
HOUSE SEWER CONNECTING, TO.
PUBLIC SEWER @ $3.00 I � TYPE OF TION LENGTH FROM
SEPTIC TANK,SEEPAGE PIT OR Y° CURD P:L, M. TO P,L.
PITS AND/
DRAINFIELD C $3.00
OVERFLOW SEEPAGE F17',DRAINFIELD
EXTN..CESSPOOL.DRY
@ $2.00
HOUSE SEWER CONNECTING TO P.C.NO.
PRIVATE,DISPOSAL SYSTEM � $1.00 Co.IMP, NO. < JOB No. (}
CONNECT ADDITIONAL BLDG.OR TRUNK PERMIT NO. ROAD PERMIT NO. �
WORK TO ROUSE SEWER $1.00
ALTER,REPAIR OR ABANDON HOUSE STATE ENCROACHMENT 0
SEWER OR DISPOSAL SYSTEM —c -00 PERMIT NO, �}
INDUSTRIAL LUa,
- - V?ASTE APPROVAL an
CHARGES z
S+ ,fie ` PERMIT S 2.. DQ CONNECTION CHARGE.FEE
ATTsa aHOMATI TOTAL FEE REIMBURSEMENT FEE .
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVAM SIGNATURE
TO THE PUBLIC SEIWER.
SIGNED THIS '' DAY S. 19 NEW HOUSE SEWER
OWNER OR
OWNERS AGENT ¢ - .". ,. CONNECT ADDITIONAL - -
'`" BUILDING OR.WORK
ADORES SEPTIC TANK„SEEP.PITS)
AND/011 DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS A PLICATION
AND STATE THAT THE ABOVE IS. CORRECT AND AGREE TO COMPLY CESSPOOL Q DRYWELL
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AN PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND �r
LICENSED AS REOUIR BY LOS APIGELE CONTY AND STATE OF PBANDON HOUSE SEWER
CALIFORNIA OR TFi A APA I LEGA I3WNER .,aF THE ABOVE _DESCRIBED RESIDE IAL PROPERT '` �I v BACKFILL SEPTIC TANKS — Q
SIGNATURE F SEEP,PITS Q CESSPOOLS
OF PERMITTEE ”
s
-,----VAlMATION ROBERT A. WOOD
i
CK.:•,+' A.0. CASH SUPERVISING MECHANICAL ENGINEER
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