HomeMy Public PortalAbout5822 TEMPLE CITY BLVD_Sewer__ 76A642BAPPLICATION FOR PERMIT
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DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL
Department of County Engineer _
County of Los Angeles BUILDING
JOHN A. LAMt3!>., COUNTY ENGINEER _ADDRESS )
a CASSAT`; D.GRIFFIN, SUPT OF BUILDING
v LOCALITY,,.,'' '�,e � ,r��a ,..�,r NEAREST
FOR FOR APPLICANT TO FILL IN CROSS ST..�
LEGAL
DESCRIPTION LOT NO. .,`, ,- 2P --OWNER .r'�'�r' -,/ ✓ .i.�,�n
MAIL
.BLOCK TRACT ADDRESS
N0.OF BLDGS.- ----
SIZE.OF LOT NOW ON LOT CITY- TEL. NO,
USE of � r
BULDINGS '6'✓�' � 1 DISTRICT NO. GROUP MAP
13K Pill
CONTRACTOR
CONNECTION DATA
ADDRESS - '� -
STATION :;a 5
TEL. N0. - .- --. DEPTH
`- -" � -
�_--. MANHOLE REFERENCE UPPER
+.,
2-STATE - — -------a:,a'-'""'�--�`--..� ✓, ,_.v WER"`';
-r
REGISTRATION NO. [I -
NO. j DcSCRIPTfQN OF WORK FEE - -- -- ---- --- ---
----t -- — - ----- -- —.. —.- TYPE OF CONNECTION „� LENGTH FROM
i HOUSE SEWER CONNECTING TO i Y. CURB L. bI L TO P L. d �"
PUBLIC SEWER rV. $3.5 0 I3' ----- - -----; �-------------`"'°'---
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DkA[NFIELD I _
OVERFLOW SEEPAGE PIT, DRAINFIELD .. PC, NO,
FXTN ,CESSPOOL,DRYVvEL.L,MANHOLE $2..00 ! CO. IMF, NO. -' ', 1O6 NO.
HOUSE SEWER CONNECTING TO---- -- ---- -
PRIVATE DISPOSAL SYSTEM 1.00 TRUNK PERMIT NO. - ROADPERMITNO. _
CONNECT ADDITIONAL BLDG OR STATE ENCROACHMENT
WORK TO HOUSE SEWER $1.00 � � PERMIT NO. _-_-
ALTER,.REPAIR OR ABANDON HOUSE ! INDUSTRIAL
SEWER-OR DISPOSAL SYSTEM C_ ,*"'1.00 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OdVNEIt'S1 PERMIT 00 ----- - ------------------- ..
5
REIMBURSEMENT FEE
AUTHORIZATION TOTAL FEE 4p I :��
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- APPROVALS I DATE IINSPECTOR.S IGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. NEW HOUSE SEWER
SIGNED THIS d�
AAI' OF °-- •, ✓ ,' --- ---- -- -----
,� i +�'� CONNECT ADDITIONAL
OWNER OR .'•� BUILDIt U OR WORK _
OWNERS AC,ENT —e .r,'W�.fr,.�'
TANK,� -11 r SEPTIC TAN .,SEEP PIT(S)
ADDRESS ."' 'pY' t ry � T"✓d AND/OR DRAINFIELD----- Iff--....---�.--'
I HEREBY A KNOT LEDGE; THAT I HAVE READ THIS APPLICAT10Pd CESSPOOL❑ DRYWELL!]
AND STATE T}�rr't"'THE ABOVE 1S CORRECT AND AGREE TO COMPLY ___.____�_.—_
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,RE.PAHii SEWER OR ;.
PLUMBING AND SEWERS. _SEWAGE DISPOSAL SYSTEM _
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ! I
LICENSED AS REOUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND I
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE ___A__ N HOUSE SEWER
DESCRIBED RESIDENT,!".,PROPERTY. BACKFILL SEPTIC TANKSC
`) POOLS C
�.,
a 2�' SEEP. PIT( CESS _ — --1
SIGNATURE - 3�'''.^' _ ,
OF PERMITTEE - '`. "`" L•+:'
1OHN A. LAMBIE, COUNTY ENGINEER VALIDATION— ROBERT A.WOOD,CHIEF PL13G, INSPECTOR
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CK. M.0. Of CAS '..