HomeMy Public PortalAbout5910 TEMPLE CITY BLVD_Sewer__ 2808 ° APPLICA ION FOR PERMIT
COUNTY OF LOS ANGELES SEWER--SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS
JOHN A. LAMBIE, County Engineer
CASSATT D. GRIFFIN, Supt of Building LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL _
DESCRIPTION LOT NO. OWNER
BLOCK TRACT { , V4 MAIL
µ ADDRESS
NO.OF BLDGS.
SIZE OF'LOT NOW ON LOT CITY TEL. NO.
USE of
BUILDINGS DISTRICT NO. GROUP MAP PROCESSED BY
BK PG
CONTRACTOR s �' I mo, ✓
ADDRESS CONNECTION DATA
CITY 7EI.,NO, STATION DEPTH
REGISTRATION'N0.—. STATE' MANHOLE REFERENCE _ UPPER
Q COUNTY LOWER
N0. DESCRIPTION OF WORK—FEF
HOUSE SEWER CONNECTING TO
PUBLIC SEWER $3.00 CONNECTION a LENGTH FROM-�--�—
SEPTIC TANK,SEEPAGE PIT OR Y. CURB P.L. M.L.TO P.L.
ITS BAND/OR DRAINFIELD @ $3.00
OVERFLOW SEEPAGE PIT.DRAINFIELD
EXTN..C:SSPOOL..DRYWELL @ $2.00 —
HOUSE SEWER CONNECTING TOP.C.NO,
PRIVATE DISPOSAL SYSTEM @ $I_.00 CO.IMP, NO. JOB NO.
CONNECT ADDITIONAL.BLDG.OR2 - TRUNK PERMIT N@ � ROAD-PERMIT N0.
WORK TO;LOUSE SEWER @ SI.00
ALTER,REPAIRBANDON HOUSE —STATE ENCROACHMENT
® SEV1'ER OR DISPOSO.R AAL SYSTEM Cod $1.00 PERMIT'NO.
INDUSTRIAL - >
WASTE APPROVAL
CHARGES
OWNER'S PERMIT s 2 OO CONNECT16N CHARGE FEE
AUTHORIZATION TOTAL FEE p REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR°S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED? THIS DAY OF 19— NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
SEPTIC TANK,SEEP.PIT(S) �
ADDRESS AND/OR DRAINFIELD
HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
ANP STATE THAT THE ABOVE 15 CORRECT AND AGREE 'TO COMPLY .CESSPOOL 0 D_RYWELL Ci
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF THE ABOVE —
DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS ❑
SIGNATURE ,;
SEEP.PIT(S) CESSPOOLS L7
OF PERMITTEE
R ' , ""VA DATION ROBERT A. WOOD
CK,IS Y,0. CASH SUPERVISING MECHANICAL ENGINEER