Loading...
HomeMy Public PortalAbout5834 TEMPLE CITY BLVD_Sewer__ 08 CE842D � 76*42D APPLICATION FOR PERMIT' COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION ADDRESS JOHN A. LAMBIE, County Engineer ADDRESS �K WILLIAM A. JENSEN, Sup'8 of Building LOCALITY NEAREST FOR APPLICANT TO FILL IN CROSS 5T. LEGAL ._- .` as. _ OWNER _ `, Y._ LOT NO S"j DESCRIPTION _ MAIL —_ BLOCK TRACT /1,,� ADDRESS NO. OF BLDGS. SIZE OF LOT iR NOW ON LOT � .., _ CITY - TEL. NO, USE OF BUILDINGDISTRICT NO. GROUP MAP 1ROCE55RD'BY PG CONTRACTOR > � �1' _ i ADDRESS _ ` � _CONNECTION_ DATA -------- STATIONDEPTH - N CITY _ ` UPPER ��y "43"-T-41-7 '4 3y��� STATE MANHOLE REFERENC E"'�. REGISTRATION NO. ` ,..�` COUNTY � ..� '1 / ! _iii• y NO. GHSCRIPTION OF WORK FEE_ TYPE OF CONNECTION , M! 7. I HOUSE SEWER CONNECTING TO Y. CURB ,-FrL. _ M.L.TO FI:L. PUBLIC SEWER @ $5.00 ------- N P.C.NO. SEPTIC TANK SEEPAGE PIT OR 136 PITS AND/OR DRAINFIELD @_$10._00 — co_I MP.NO. CI .108 NO. HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. ------ U PRIVATE DISPOSAL SYSTEM @ $3.00 CONNECT ADDITIONAL BLOG OR AFFIDAVITWAIR€R[ps€HENT RECORD.XNSTR.NO. DATE WORK TO HOUSE SEWER @ $3.00 F OVERLOW SEEPAGE PIT DRAINFIELD EXTN,CESSPOOL,DRYWELL MANHOLE @ $5.00 LU V M 'ABANOON HOUSE -- (4Yd�OR SrT.WtD$NGN G. J _ -" _- O. SEWER OFrB55�©S_7�L SYSTEM @ $3 OO_ �(.- .._.' STATE ENCRQi,FHMEN / PERMIT N<V u. Z -V -f-t-` -- INDUSTRIAL WASTE APPROVAL OWNERS PERMIT ss� ij Oo -- CHARGES AUTHORIZATION TOTAL FEE `, CONNECTION CHARGE FEE -- -- '1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS TO THE PUBLIC SEWER. DATE INSPECTOR'S SIGNATURE SIGNED THIS--DAY OF --"`---'--- OWNER OR NEW HOUSE SEWER OWNERS AGENT CONNECT ADDITIONAL BUILDING OR WORK. ADDRESS--- SEPT I C DDRESS_ SEPTIC TANK,SEEP,PIT(S) ` I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD AND STATE THAT THE, ABOVE IS CORRECT AND AGREE TO COMPLY ----------- WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING PLUMBING AND SEWERS. CESSPOOL ❑ DRYWELL ❑ IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTE R,REPAIR,SEWER OR LICENSED AS REQOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM CALIFORNIA 0R UIRBV T ! A NLE ED R�` DON HOUSE SEWER LEGAL OWNER OF, AND I DISCONNECT PLUG AND RESIDE IN, THE B VE DESC IDENTI L PROPER d f +Q �\py` � ARAN .� �( ��• +�.;'-F,F - SIGNATURE \ L - --- Y ) BACKFILLSEPTIC TANKS M ❑ OF PERITTEE_- T _ ,J" �e�w-- -°�---�..-t -- SEEY,PIS? ❑ CESSPOOLS ❑ VALI ATION ROBERT A. WOOD f CK. M.o. cases SUPERVISING MECHANICAL ENGINEER i