HomeMy Public PortalAbout5821 TEMPLE CITY BLVD_Sewer__ 78R642BM
APPLICATION ION FOR PERMIT 1
DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL
Depwtment of County Engineer
County of Los Angeles BUILDING > x
JOHN A. LAMBIE, COUNTY EiVGINEER —ADDRESS ,-_`
CASSATT D, GRIFFIN, SUPT OF BUILDING LOCALITY
NEAREST ' —_
FOR APPLICANT TO FILL IN
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LEGAL OWNER
DESCRIPTION LOT NO. - i'_ — -
y MAIL
BLOCK TRACT +' _ADDRESS
NO.OF SLOGS.
NOW ON LOT CITY TEL. N0.
SIZE OF L
USE OF DISTRICT NO. GROUP
BUI.LDINGS _ _ ., MHP
�514 BK PG
CONTRACTOR `�` �,. ,��. �•
,ADDRESS � e/�; -,,.. _ _ CONNECTION DATA -
dP
r:'a^ STATION
C ..%�,, ,�- t TEL. NO, MANHOLE REFERENCE ✓ �"� .._ __
j� �," r' ��' ❑ STATE. OWER
: --
REGISTR,A'iION NO. d ❑ COUNTY — —
I)ESCRIC'T ( N CSF WORK PEE ---- --- ------
HOUSE SEWER CONNECTING TO TYPE OF CONNECTIO LENGTH FROM #` -
_•,_ �Gi31'E4. P.L. M L TO P.L.
PUBLIC SEWER $3.50 .---------
SEPTIC-TANK,"TANK SEEPAGE PIT OR
PITS AND/OR DRAINFIELD i<[;. $3.00
-- "j-OVERFLOW SEEPAGE PIT. DRAINFIELD F C N0.
a �m
EhIN ,CESSPOOL,DRYWELL,MANHOLE @T' $2.00 CO. IMP h0. JCB N0.
j HOUSE SEWER CONNECT NG TO
PRIVATE DISPOSAL SYSTEM CI $1.00 TRUNK PERMIT NO. - __ ROAD PERMIT NO.
CONNECT ADDITIONAL BLDG OR
fid ---- STATE E N CRLYA.G,}�MENT
WORK TO HOUSE SEWER .
--_ --3-7.0:0 � PERMIT NO.
ALTER,REPAIR OR ABANDON HOUSE / INDUSTRIAL
SEWER OR DISPOSAL SYSTEM Cu` -"
--__-- _-- _ $1_00 1„--- WASTE APPROVAL
CHARGES
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--- ._.--._--�., ----- -----_
CONNECTION CHARGE FEE
OWNER'S PERMITS 11 -- - -- --- _.__ --
AUTHORIZATION TOTAL FEE ' oD REIMfY3RSEMENr FEE
I
HAVE AT THIS DATE A CONTRACT WITH THE HEREI,IS NAMED CON- APPROVALS DATE 'NSPECTOR'S SIGNATURE
TRAC]"OR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
------------ --__----'-. -----4- — -- ----__...---
TO i-HE PUBLIC SEWER. - NEW HOUSE SEWER - 11
SIGNED THIS- DAY -
�- _ CONNECT ADDITIONAL
OWNER OR ,: ". j' r' BUILDING OR WORK -
OWNERS AGENT,;"
»- `> '' !y i._''' rQ'.�'•, A_.�.�. SEPTIC TANK,SEEP,P11T{S1 .
_ADDRESS__. _ _AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL-D DRYWELLL.I.
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY _._._----._--`--_--_'--..._.,•--�_L—.---'----_— _._
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUkSING AND SEWERS. SEWAGE DISPOSAL SYSTEM
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HEREBY
CERTIFY THAT I F.N PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND — --_ ---^--- --�---
LiCENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE
SEW ER
CALIFGRNIA OR T} 1 AM THE LEGAL OWNFFR OF THE ABOVE
DESCRIBED RE 1,PENTI L PROPERTY � —� .-. .-----f----- I .-�----
- //r BACKFILL SEPTIC TANKS 0
SiGNA.T'URE d� d..�`� ,� SEEP-PITS) CFSSPOOLS
-SEEP. - S)---
OF PERMITT -,r -"✓ s= A .- — - _�-
1
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JOHN A. LAMBIE,COUNTY ENGINEER VALIDATION_y= ROBERT A.WOOD,CHIEF PLeG. INSPECTOR
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