HomeMy Public PortalAbout5835 TEMPLE CITY BLVD_Sewer__ DEPARTMENT OF COUNTY ENGINEER SEWER—SEWAGE DISPOSAL 1
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER I BUILDING y --
ADDRESS ) `� 6
FOR APPLIC T TO I LOCALITY 7
BUILDING �y _ NEAREST
ADDRESS:�+ CROSS ST. --�j�J
LOCALIT _ 4 DISTRICT NO. SERIAL NO. PERMIT NO. C
NEARE J• A �!] S
CROSS -
_RBY Ready for Inspection DJVE ISSUED
OWNER L/,,
MAIL /� ?,
ADDRESS �� + ,/ qCi" 'I USE 201IE/ OCCUPANCY BK MSP PG
CITY EL.NO.,A/rI'
CONTRACTOR r_
c - -CO.IMP.NO. Z. � p'
ADDRESS , �/ / JOB.NO.
CITY L._/d� TEL.NO.j.-99 &a7&10
STATE
:TRUNK PERMIT NO.
REGISTRATION NO. / 3 o % L/ H COU TY ROAD PERMIT NO.
LEGAL
DESCRIPTION LOT N0. ulg z b �6 3 'STATE ENCROACHMENT
PERMIT �-+ �/ s�
BLOCK TRACT �+�y�� NO.
/ WASTE'A PROVAL _1 �fE�• l;?A�.
S12E OF LOT 4PJ K/ i7 NOW ON LOTS CHA EB..
USE OF EEBUILDINGS 29,5% CONNECTION CHARG
_
NO. DESCRIPTION OF WORK FEE REIMBURSEMENT FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER a $ 3.00 RECEIPT N0. I DATE I BY'
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.OR EXCEPTIONIR&CORDED
WORK TO HOUSE SEWER 1.00 NO.
ALTER OR REPAIR EXISTING / I DAT I BY
SEWER OR DISPOSAL SYSTEM 1.00DISCONNi
AND/OR DISPOSALSYSTEMABANDON SEWER .`1.00 CONNECTION DATA
PEPTIC TANK,SEEPAGE PIT OR /
PITS AND/OR DRAINFIELD 2A0 STATION DEPTH
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 2.00 '�, MANHO�AGW- ER`LFERENCE LOW
TYPEt07F CONNECTION LENGTH FROM
OWNERS PERMIT ; 1 00 r P.L. M.L.TO P.L. 7
AUTHORIZATION TOTAL FEE
1 HAVE THIS DATE CONTRACTED WIT E HEREIN NAMED
CONTRACTOR TO CONNECT THE ABO ESCRIBED EXISTING APPROVALS INSPECTOR' SIGNATURE DATE
DWELLING TO THE PUBLIC E
SIGNED THIS. D FZer. -P 1' NEW HOUSE SEWER �a�s ✓�. a
OWNER OR CONNECT ADDITIONAL
OWNERS A,GE°--N _� .. BUILDING OR WORK
ADDRESS...>wl� _� - SEPTIC TANK,SEEP.PIT(S)
AND/OR DRAINFIELD
I HEREBY ACKNO LEDGE IWAT I HAVE READ THIS APPL1- CESSPOOL[] DRYWELL
CATION AND STATE THAT THE ABOVE 18 CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER.REPAIR,SEWER OR
REGULATING PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOPLUG AND
AND SDISCONNECT PLUG AND
TATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN-
ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS
SEEP.PIT(S)[:] CESSPOOLS
SIGNATURE efrs�^�"� v
OF PERMITTEE__- -----•---.._ 1 ......---_....._._.._`------.�_.._.._
76AG42A 663 7/03 ].