HomeMy Public PortalAbout5820-5820 1/2 TEMPLE CITY BLVD_Sewer__ APPLIC TION FOR P MIT
:,sos_a.ffis
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. I.AMBIE, County Engineer ADDRESS ,-
7
CASSATT D. GRIFFIN. Sup't of Building LOCALITY / ✓
NEAREST +y r
FOR APPLICANT TO FILL. IN CRDS 'T. ', '• L 3-""-
LEGALz
DESCRIPTION LOT NO. s OWNER r
BLOCK TRACTMAIL
, '�j ADDRESS
NO. OF BLDG$.
SIZE OF LOT NOW ON LOT I CITY TEL.NO.
USE OF
BUILDINGS DISTRICT NO., GROUP MAP P?OCESSED BY
1 Br PG
CONTRACTOR
ADDRESS + so - $TILI ` -._. CONNECTION DATA
CIT ,q � �TEL.NOA P STATION DEPTH
y S ENC .
REGISTRATION 0. , MANHOLE REFUPPER
COUNTY � LOWER
---
xa. GESCRIPT15 'OF WORK FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER Q $3,00
SEPTIC TANK, SEEPAGE PIT OR TYPE FCONNECTION LENGTH FROM
PITS AND/OR DRAINFIELD @ $3.00 Y. CURB P.L. M.L.TO P.L.
OVERFLOW SEEPAGE PIT, DRAINFIELD
EXTN.,CESSFOOL,ORYWELL,MANHOLE @ $2.00 .,
HOUSE SEWER CONNECTING TO P. 0
PRIVATE Di$I SAL SYSTEM @ $1.00 CO.IMP,NO. WS NO.
CONNECT ADDITIONAL BLDG.OR q
WOR.K TO HOUSE,SEWER @ $1.00 •sy TRUNK PERMIT N0, ROAR PERMIT N0.
ALTER,REPAIR OR ABANDON HOUSE STATE ENCROACIiMEy
SEWER OR DISPOSAL SYSTEM @ $1.00 PERMIT NO, /
INDUSTRIAL
-- WASTE APP eAL
CHARGES
OSS mws PERMIT s 2 OO CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE � �A REIMBURSEMENT FEE
�C
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. APPROVALS DATE INSPECTOR'S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER.
SIGNED THIS DAY OF I9� NEW HOUSE SEWER
OWNER. OR CONNECT ADDITIONAL -
OWNERS AGENT BUILDING OR WORK
SEPTIC'PANK,SEEP,AIT(S)
ADDRESS AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE A80VE IS CORRECT AND AGREE TO COMPLY CESSPOOL.E7 DRYWEI_L
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER, REPAIR.SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HERESY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LDS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE - —
DESCRIBED R5 ENTIAL )•'B42PER;7'ts, BACKFILL SEPTIC TANKS❑
SIGNATURE - P ! SEEP,PITS) ❑ CESSPOOLS[I
OF PERMIT! f
RIF J "IMATION-- ROBERTA.WOOD
}✓ 6Ke /M.Q. CR8tG SUPERVISING MEGMANICAL ENGINEER
Y f f