HomeMy Public PortalAbout5812-5814 TEMPLE CITY BLVD_Sewer__ DEPARTMENT OF COUATTY ENGINEER SEWER--,SEWAGE DISPOSAL
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER BUILDING
ADDRESS ;
FOR APPLICANT TO FILL IN LOCALITY '---- r"
BUILDING ,� h j' NEAREST
ADDRESS l �.� ' j��—t / . r'; f K,•�tG _ CROSS ST. ;r.
LOCALITY ® DISTRICT NO. SERIAL NO. PERMIT NO.
NEAREST t"a -t .-
_ j
GROSS SL
RECEIVED BY Ready for Inspection DATE ISSUED
OWNER
MAIL ,w1
ADDRESS 17 - > USE ZONE OCCUPANCY BK MAP PG
CITYL�?�,,,�: ,+C...-� TEL.NO. 7"'
CONTRACTOR f j
' CO.IMP.NO.
ADDRESS,',4/. amt
JOB.NO.
CITY /r �,�y TELAO. a+ TRUNK PERMIT NO.
REGISTRATION NO. �% r /, •e° �j STATE
a" LJ COUNTY ROAD PERMIT NO.
--- �
LEGAL —
DESCRIPTION LOT NO. ' ++� STATE ENCROACHMENTPERMIT NO.
BLOCK TRACT i✓ INDUSTRIAL
WASTE APPROVAL
SIZE OF LOT NO.OF BLDG$.USE OF CHARGES
NOW ON LOT
BUILDINGS CONNECTION CHARGE FEE
NO. DESCRIPTION OF WORK FEE
REIM13URSEh1ENT FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER @ $ 3.50 ')� RECEIPT N0. DA BY
HOUSE SEWER CONNECTING TO I
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.OR EXCEPTION RECORDED
WORK TO HOUSE SEWER 1.00
ALTER OR REPAIR EXISTING NO, DATE I BY
SEWER OR DISPOSAL SYSTEM 1.00
DISCONNECT AND ABANDON SEWER
_ AND/OR DISPOSAL SYSTEM 1.00 CONNECTION_DATA
SEPTIC TANK,SEEPAE
--PITS AND/OR DRA NFGELD T OR 2.00 STATIONpp� DEPTH
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 2.00 MANHOLE REFERENCE
aYCw UPPER
TYPE OF CONNECTION LENGTH FROM
Y. ,."d1Y -;ice. M.L.TO P.L. I
OWNERS PERMIT ; I 0v � �
AUTHORIZATION TOTAL FEE
1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER
SIGNED THIS----_--------------DAY OF...._......_•--._......._.—......19__... NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT....----.------...-. BUILDING OR WORK
--------..._.•_--.....-.-_.._-.....-..._.-_..._ SEPTIC TANK,SEEP.PIT(S)
ADDRESS_.......................................................................... ._... AND/ORDRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI. CESSPOOL 0 DRYWELL
CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER,REPAIR,SEWER OR
REGULATING PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED DISCONNECT PLUG AND
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOUSE SEWER
AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN-
ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS
SEEP.PIT(S)[:] CESSPOOLS
OF PERMIRE ZoTTEE- .`s�`,�d.-'. ,._6 : '! ::1..:�,y�
76A642A 663 7/53 A4 sY'