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HomeMy Public PortalAbout5822 TEMPLE CITY BLVD_Sewer__ 76A642BAPPLICATION FOR PERMIT 3&E-E58 It-55 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 K CK. M.0. Of CAS '..