HomeMy Public PortalAbout5837-5839 TEMPLE CITY BLVD_Sewer__ 76AE-SaS 3.55 APPLICATION FOR PERMIT
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DIVISION OF BUILDING AND SAFETY SEWER--SEWAGE DISPOSAL
Department of County Engineer
County of Los Angeles BUILDING
c- .
ADDRESS � d
WM.J. FOX, COUNTY ENGINEER -
CASSATT A.GRIFFIN,SUPT OF BUILDING LOCALITY F411 J
d. a
NEAREST
FOR APPLICANT TO FILL IN _CROSS,s7,
LEGAL
DESCRIPTION LOT NO. # s 1 t-�`:.� _OWNER
BLOCK TRACT 2 MAI- 1, -
'+ - - ADDRESS
SIZE OF 1_07 +r C."t1 WON LOT `l _ CITY j`- TEL,1;0. i!
USE OF - I'
BUiLD?NGS_ DISTRICT NO: GROUP MAP PG
TCONTRACTOR �+� tL p � �- K Pr.4t
ADDRESS ,;«-^ ✓ CONNECTION DATA ��_�^,_
CITY— �' TEL. NO. -- STATION_ ", ['' DEPTH- --
-,-- MANHOLE REFERENCE 40A UPPER
REGISTRATION NO, COUNTY
COUNTY
No. DESCRIPTION 6F WORK FEE
-- ------ --'� TYPE OF CONNECTION---ftLENGTH FROM yo C.
Z_PUBLIC
SEWER CONNECT I CJ6 TO ,_`' _�.
PUBLIC r SEWER _ S 3 50� _ -Y=
----— CURB .L __M.L. TO P.L.
HOUSE SEWER CONNECTING TO
PRIVATE DI-SPO-SAL SYSTEM 1.00 i — —"- --------. .
CGN -CT ADDITIONAL ELDG.OR _ P C. N0. --
_ V<CRF: TG HOUSE SEWER_ 1.001 CO. ?"1 P. NOJOB NO.
—
ALTER NOdREGt REPAIR £atSTihGSEWER DISPOSAL _
---- TR—UNK PERMIT
IT NO__---
--- ROAD PERMIT NO.
ND ABANDON SEWER STATE ENCROACHMENTAND/OR DISPOSAL SYSTEM1.00 , PERh7T NO.
SEPTIC TANK, SEEPAGE PIT
_"--INDUSTRIAL --
_ i P175.ANDtOri DRAIhFiELO — 04 — --._--_ ------
CESSPOOL ORYU E'LL
W8PTE APPROVAL
.� SPECIAL CONDITIONS ONLY 2.00 _ - CHARGES
-- ----'- CONNECTION CHARGE FEE
A T ®FIZ.FiTI®t7 TOTAL FE . REIMBURSEMENT FEE
_
A —
I
HAVE THIS DATE CONTRACTED WITH THEI- -M
HEREIN ED CON- APPROVALS
�
TRACTOR TO CONN F.G7 °ia BOVE ❑ES�IBED EXISTING UNELL ?=.G ROV 5tOV1�,LS DATE INSPECTOR'S SIGNATURE,
TO TH PUBLIC f WE-P"
GITHIS' NEW HOUSE-SEWER
SIGNED —DAY OF —.— t — -- -- - -
OWNER OR ip w..-. CONNECT ADDITIONAL j
OWNERS AGENT d.f BUILDING OR WORK
-- ,�"` .-SEPT' TANK,SEEP. PIT(S)
ADDR£S ' *{'"�^ ANVOR_DRA!NFIELD
AND
f HER BY ACKtJ01YLEDGE THAT I HAVE READ T 19 APPLlCAT10N CESSPOOL[jDRYWELL CI
SLATE T,{AT ''HE ABOVE ZS CORRECT A+?D AC2EE TO COMPLY __
WITH ALL
PLUML-`tNG AND D SURDfNANCES AND STA7L'TIEA' S nEGULATIN6. ALTER,REPAIR,SEWER OR
SEWERS, _SF,4i+AGE DISPOSAL S1'SYE1.1
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ��FWAGE __�--YST -
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND
C LIFORNIA OR THAT I AM THE LEGAL OWNER OF T.SiE ABOVEABANDON ILC 5E
SCRIBED SYDE IAL GROPER�(. `BACKFILL SEPTIC.TANKS
U
N/ 1y — ,, T
SEEP.PIS) [,] CESSpOOLS0_ ._ �...._T...___
'OF PER-IF �'E
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WILLIAM J.F X, COUNTY ENGINEER VALIDATION R.A.WOOD, CHIEF PLBG. INSPECTOR
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