HomeMy Public PortalAbout5808 TEMPLE CITY BLVD_Sewer__ '$ 04.8
:xAPPLICATION FOR PERMIT
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COUNTY OF LOS ANGELES SEWER—SEWAGE D I S POSA L
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDINGS
JOHN A. I.AMBIE, Count ADDRESS � 08-1 1e am City B w
CANATT D. GRIFFIN,Supl of Building LOCALITY €� rt'�
CROSS Slit)
FOR �PLIC;F�NT T�7 F'II.I. IN _ ;..�.�.
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ESCRIPTION LOTNU .> =R: o�vrlBR kl `
" MAIL -
c � ;,�
m ADDRESS 1i'1 °� TSI. ..
NOWON LOT CITY G TEL.NO.
2Rep, - DjISTRICT CdA. GROUP MAP PR�9CESSED BY - I
Bid P6
CANTRACTOII,Sauar Deal Sewer Se `vice �� „t
ADDRESS 3 axson d. _ CONNECTION D1 A
CITf,,iE1 Mo hh e TEL.NO..G 14-2020 STATION 7
ISI :. w x DEPTH 1�,
REGISTRATION NO. STATE mMANHOLE REFERENCE '- UPPER.
u COUNTYZ ' 4dd r LAWER ,,
NO. I DESCRIPTION OF WORK FEE �p*qq
"HOUSE SEWER CONNECTING TO �C�
PUBLIC SFW:R @ $3.00
trYPE OF CONNECTIO LENGTH FROM
SEPTIC TANK,K,SEEPAG.�E,yPIT OR
PITS ANO/OR Y. CURB F Lam-' M.L.TO P.L. J° �...-
7?.Atfv,_.,-D C. $3,00 _
OVERFLOW SEEPAGE PIT,DRAINFIEC,D
EXTN.,CESSPOOL.DRYWELL,AIAhHOLE $2.00
HOUSE SEWER CONNECTING TO � P.C.NO.
PRIVATE DISPOSAL SYSTEM $1.00 CO.IMF.NO, l &'"-' moo, JOB NO.
50YOR E Q CT I�0�SEISEN R BLDG.OR $1,00 1 00 TRUNK PERMIT NO, ROAD PERMIT NO.
ALTER, REPAIR OR ABANDON HOUSE STATE FNCROACHMEIdT
SEWER OR DISPOSAL SY'STEhI $1.00 _PERMIT N0.
INDUSTRIAL
WASTE APPROVAL
��7
- - CHARGES "
OWNEWS PERMIT s 2 BO CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE r REIMBURSEMENT t:EE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. APPRC DATE I":YSPECTOR'S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER,
SIGNED THIS—DAY OF I9— -NEW HOUSE SEtv>AR
OWNER OR CONN IN ADD➢ ORK
OWNERS AGk,IdT�...� m.,. L'UILDING OR WORK
SEPTIC TANK,SEEP,PITS)
ADDRESS — AND/OR
_ DRAINFIE.LD
I HFFREPY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION _ �AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL 0 DP?VELL_
WITH ALL, COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR -
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR -SEWAGE
PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF rISCONid HOUSE AND
CALIFORNIA OR THAT I AM THE LEGAL OWNER. OF THE ABOVE
EWER
DESCRIBED RESIDENTIAL PROPERTY, BACKFILL SEPTIC TANKSSIGNATURE [J
SEEP.PITS) L7 CESSPOOLS
OF PERMITTEE Ij
VAIIDATION ROBERT A.WOOD
CPQ, M.0. CASH SUPERVISING MECHANICAL ENGINEER
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