HomeMy Public PortalAbout5758 TEMPLE CITY BLVD_Sewer__ 29650 1NSE7€T5
768086.60 APPLICATION FOR PERMIT
76A6s2D COUNTY OF LOS ANGELES SEWER-SEWAGDISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
°'
IFIN A. LAMBIE, County En ixteas ADDRESS r
WI®LLIAM A. JENSEN, Supt of Building LOCALITY d
FOR APPLICANT TO FILL IN CFO's S�. _
LEGAL
DESCRIPTION LOT NO. k.++ �'e+' d'� OWNER
MAIL ti
BLOCK TRACT ".. -+'
NO.OF BLDGS. ;
SIZE OF LOT NOW ON LOT CITY +g.. ' ... TEL NO. -u, '
USE OF d e s- DISTRICT NO. GROUP MAP PROCESSED BY
CON
.BUILDINGS r .`-
CON -�- BK PC �
TRACTOR � �,+�
AD➢REss J.�' ;� • ;' _- '.. �� ��>> � CONNECTIOI�I DATA
CITY r' TEL.No- ' STATION G DEPTH
ysy�r STATE MANHOLE REFERENCE ,
REGISTRATION NO. '(dam+mow� COUNTY `` LOWER
NO. DESCRIPTION OF WORK FEE
aY
PHOUSEUBLIC
S CONNECTING TOO
PU§LI
!_ C SEVtWER_ C� 59.00 � TYPE O TION LENGTH FRON(y."
SEPTIC T'4NK,SEEPAGE PIT OR Y. CURB P.L. M.L.TO P.L.
PITS AND/ORDRAINFIELD P $3.00 -
OVERFLOW SEEPAGE PIT.DRAINFIELD -
E7.TN..CESSPOOL. DP.YWELL @ $
2.00
HOuSE SEV4F.R CONNECTING TO g P.C.NO.
PPP, ATE.DISPOSAL SYSTEM @ 51.00 CO.IMP. td O. JOB NO. y,
CONNECT ADDITIONAL BLDG.OR t:
W ,,K TO HOUSE SEWER @ 51.00 jr TRUNK PERMIO. ROAD PERMIT NO. - 0
T N
Al-SER, REPAIR OR ABANDON HOUSE STATE ENCROACHMENT FA
SEWER OR DISPOSAL SYSTEM $1.04 _PERMIT NO.
INDUSTRIAL t
WASTE APPROVAL
CHARGES
OVNER`S PERMIT 2( 90 CONNECTION CHARGE FEE
-AUTHORIZATION TOTAL FEE *. .' f REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS I DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWS --^
SIGNER THIS F �� i9 NEW HOUSE p
OWNER OR _ - - -^ -
ADDITIONAL
OWNERS AGEN BUILDING OR WORK
!,w 5EP7fC TAtdK, P..PITS)
ADDRESS SEE
AND/OR DRAINFIEI.D
I HEREBY ACKNOWLEDGE THAT I HA READ THIS APPLICATION
AND STATE TIiA'I' THE ABOVE IS CORK - T AND AGREE TO COMPLY CESSPOOL D DRYWELL Q
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. ALTER,REPAIR,SEVER OR
--� SEWAGE DiSPOSAL SYSTEM
1 HEREBY CERTIFY Y' I A_ PROPE Y REGISTERED AMD/OR DISCONNECT PLUG AND
LICENSED AS REOUiR . Y L. A:.- LE. COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THA AM 'THE L GA OWN,,.R1.O€ T ABOVE --
DESCRIBED R IDEh�.T'i PROP#�RTY. �; BACKFILL SEPTIC TANKS
SIGNATUREr ,,¢. SEEP. PITS} [] CESSPOOLS Q
OF PERMITT
F' �° LIDATI07 ROBERT A. WOOD
iff SUPERVISINCs MECHANICAL ENGINEER
CK. N.9. W1SM
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