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HomeMy Public PortalAbout5816 TEMPLE CITY BLVD_Sewer__ DEPARTbfCl NT OF COUNTY ENGlNE= SEWER—SEWAGE DISPOSAL- DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION OIF ]LOS A.WGE MB // r4=r BUILDING WILLIAM J. FOX, COUNTY ENGINEER I ADDRESS : rr/ 6 (V„ 1: • '_ ' FOR APPLICANT TO FILL IN LOCALITY BUILDING ADDRESS r) to. , n t.ir�fC �: OSS ST. p •/f, LOCALITYDISTRICT NO. SERIAL NO. PERMIT NO. c NEAREST - g� A S / CROSS ST RECEIVEDJBY Ready for Inspection DATE ISSUED OWNER F-, lr�l•Cf'. MAIL USE ZONE OCCUPANCYBK MAP PG ADDRES O® �w; /CITYTEL.NO. , /-7 �p e o,(�t`:� � /a CONTRACTOR 01 CO.IMP.NO. {�° f`�el b 74 ADDRESS (� - W. JOB.NO.', CITY 41 eA TEL.N If, TRUNK PERMIT\NO. STATE REGISTRATION N0. ��.J`+��_�-�o�, SY. ROAD PERMIT NO. LEGAL DESCRIPTION STATE ENCROACHMENT LOT NO. PERMIT NO. !n G�°r�r = INDUSTRIAL BLOCK TRACT / c WASTE APPROVAL F'C{titldL��+I SIZE OF LOT NO- BLDGS. , NOW ON LOT , CHARGES USE CONNECTION CHARGE FEE BUILDINGS f . ��� ,�/��� NO. DESCRI I .N OF WORK FEE HOUSE SEWER CONNECTING TO REIMBURSEMENT FEE PUBLICSEWER @ 5.50 L (0 RECEIPT NO. I "�DAiE� IBY HOUSE SEWER CONNECTING TO PRIVATE DISPOSAL SYSTEM 1.00 CONNECT ADDITIONAL BLDG.OR EXCEPTION RECORDFyD WORK TO HOUSE SEWER 1.00 NO ALTER OR REPAIR EXISTING DATE �I•BY SEWER.OR DISPOSAL SYSTEM 1.00 \ DISCONNECT AND ABANDON SEWER _AND/OR DISPOSAL SYSTEM 1.00 CONNECTION DATA SEPTIC TANK,SEEPAGE PIT OR / PITS AND/OR DRAINFIELD 2.00 STATION Ly—/ �. � DEPTH CESSPOOL—DRYWELL J M NHOLE REFERENCE SPECIAL CONDITIONS ONLY 2.00 �j p .s Ja r SH D'/ UPPER }`9 m& TYPE OF CONNEGTION� LENGTH FROM OWNERS PERMIT $ 1 00 �— JUMPP.L. M.L.TO P.L. AUTHORIZATION TOTAL FEE• �. 1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED CONTRACTOR TO CONNECT THE ABOVE DESCRIBED ISTING APPROVALS EXINSPECTOR'S SIGNATURE DATE DWELLING TO THE PUBLIC SEWER SIGNED THIS_._._.__.DAY OF r__19- NEW HOUSE SEWER OWNER OR CONNECT ADDITIONAL OWNERS AGENT..._......_...__. _ BUILDING OR WORK SEPTIC TANK,SEEP.PIT(S) ADDRESS...._... _._._.._.. ._._. ._._._._.__..__.______-- _... AND/OR DRAINFIELD 1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLI- CESSPOOL[] 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 _ 1 HEREBY CERTIFY THAT I AN PROPERLY REGISTERED PLUG AND AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON DISCONNECT PLUG AND AND STATE OF CALIFORNIA OR THAT 1 AM THE LEGAL OWN- ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS SIGNATURE IQ��,�, SEEP.PIT(S)� CESSPOOLS OF PERMITTEE... ._^�" _ '_-`�.:......."'9 76A64M 663 7/53 ��1'J w�y_� i ' � 9A/