HomeMy Public PortalAbout5811-5811 1/2-5813 TEMPLE CITY BLVD_Sewer__ '.6806 5-65'
'6A6420 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSIL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING�•. �a
JOHN A. I�1�1BIF;, County 'r: f Build ADDRESS
COLEMAN V L; JF NKINS,Supt.of Building T
LOCAL Tom_,-����?��
NEARS T
FOR APPLICANT TO FILL IN cRQBs ST
LE.GAI_--
.1
DESCRIP710N LOT NO. �' �c..—� --__ OWNER —'�`/'�y�{'J4 LL ��1�,•
MAIL
BLOCK TRACT ADDRESS
NO. OF BL DGS'SIZE OF LOT NOW ON LOTCITY TEL. NO.
USE OF
BUILDINGS— �',� DISTRICT NO. GROUP MAP PROCESSED BY
B K PG
CON�JRACtL�AIO.} r�!-E!- I J.y�'?3 l 1`i 6C• -Fj �J J F
P+
ADDr�40P N. Lee Ave. q CONNECTION IATA
Q!=Y Ef MOn 'e� �TTEL..,7�N444-O';5Z8 STATION DEPTH .,
UPPER
NO.
LICENSE G 36 €w0 ( MANHOLE REFERENCE LOWER
NO. DESCRIPTION OF WORK FEE _ TYPE OF CONNECTION LENGTH FROM
H0U5E SEWER CONNECTING YO Y. CURB P.L. M.L.TO P.L.
PUBLIC SEWER $ 5.001 —
�SF'PT IC TANK, SE PAGE P!7 OR ' P.C.NO.
PITS AND,OR DRAINFIELD $10.00CO.IMP.NO. JOB NO, d
iHOUSE SEWER CONNECTING TO I TRUNK PERMIT NO. ROAD PERMIT NO. OU
PRIVATE DISPOSAL SYSTEM 2 $ 3.00!
CONNECT ADDITIONAL BLDG. OR h AFFIDAVIT WnIFEN E15EMENi RE"ORD. INSTR.NO. DATE ce
"WORK.TO HOUSE SEWER $ 3.00 •""S ( L' O
`C,LH,'REPAIRR OR aaR"NODN NousE r �- I � _ F-
'SEWER OR DISPOSAL SYSTEM = $ 3.00 _'zr I�;; U
VER FL-OWSFEfiA-GT PI T--6 A71I HWY.OR ST.WIDENING UA
I EXTN.,CESSPOOL, MANHOLE " $ 5.001 STATE ENCROACHMENT to
PERCOLATION TEST $ 5.QUj PERMIT NO, Z
--�---- --- -
INDUSTRIAL
WASTE APPROVAL
-- CHARGES
OWNERS PERMIT _ z Oo --
AUTHORIZATION TOTAL FEE
COIPNEf TT6N CHARGE FEE
A
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
TRACTOR TO CQNNECT THE ABOVE DESCRIBED EXISTING DWELLING - --- -
TO THE FU BLIC SEWER. APPROVALS DATE INSPECTOR'S SIGNATURE
SIGNED THIS DAY ----
OWNER OR NEW HOUSE SEWER
OWNERS AGENT--- — CONNECT ADDITIONAL "
BUILDING OR WORK ''h ...a ,({3'
ADDRESS =_�_
-. _-----� SEPTIC TANK,SEEP,PIT(S) F
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WIT HALL. COUNTY ORDINANCES AND STA'T'E LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑
IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR
LICENSED AS REQUIRED 13Y LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, HE VE D,: SCR.IBE REBID NT! L PROPERTY.
ABANDON HOUSE SEWER
SIGNATURE I -- - -
OF PERMITT .__` L -_ L3 ';fBACKFILL SEPTIC TANKS ❑
SEEP,.PIT($) ❑ CESSPOOLS ❑
VALIDATION
"CK. M.O. CASH
2 3 LJ D 5 t j 0—
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