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®
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/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/