HomeMy Public PortalAbout5913 TEMPLE CITY BLVD_Sewer__ -E808 10-63*
6A642D APPLICATIO_ OR PeERNUT
COUNTY OF LOS ANGELES
SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION S'JiLWNG I - I
4EIDRESS
JOHN A. LAMBIE. County Engineer
WILLIAM A. JENSEN, Sup't of Building
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F4 EID
LOCALITY
Au
_A.11 E 5
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CROSS r.
FOR APPLICANT TO FILL IN
LEC AL
DESCRIPTION k -
, LOT NO, OWNER
ADDRESS
BLOCK TRACT
NO. OF BLDGS.
SIZE OF LOT NOW 0 LOT TEL. NO. S�
USE OF DISTRiCT NO. GROUP MAP PROCESSED BY
E,u)LDINGS SK PG
CONTRACTOR 4" __-e
ADDRESS CONNECTION DATA I
STATION DEPTH
TEL NO. y. STATE
R
REGISTRATION NO COUNTY MANHOLE REFERENCE _L �.R
NO;7' �DESCRIPTION OF WORK FEE TYPE:OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y. CURB P.L. M.L.TO P.L.
PUBLIC SEWER @ $s.00
P.C.NO.
IFfiT TANK, .';AGE PIT OR JOB NO.
CO. IMP. NO.
PITS AND/OR DRAINFIELD @ $10.00
HOUSE SEWER.CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO,
F
RIVA TE DISPOSAL SYSTEM @ 53.00
DATE
A - A AFFIDAVIT "I1111 IAGii
E6KtTECT DOFFiON L 5LDG,OR I RECORD. NSTR NO
1 WORK To HOUSE SEWER @ $3,00
OVERFLOW SEEPAGEPIT.ORAINFIrLD
FX TN_,CESSPOOL,DRYWELL,MANHOLE $9.00WY,OR ST.WIDENING
-6 -4-M-EN T 7-
ISP A A111111"I'll S3.00STAT _N_CRTC
PERMIT No.
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNERS PERMIT 010
— CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE
HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE
RACTORTO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO T H E P USL!C SEWER IPPROVALS DATE I INSPECTOR'S SIGNATURE
SIGNED THIS__DAY
.—_--
OWNEROR NEW HOUSE SEWER
OWNERS AGENT-----.----..
CONNECT ADDITIONAL
BUILDING OR WORK
ADDR 55
E
SEPTIC;TANK,SFEP,PIT(S)
I HEREBY A(-.KNOWLED!3E THAT I HAVE REAL) THIS APPLICATION
AND/OR DRAINFIELD
AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO 'COMPLY
WITH ALL COUNT ORDINANCES AND STATE LAWS REGULATING
MB ING AND SEW"r RS. 'L D ELL
PLUMBING E CIESSPOO DRYWE
IHERESYCERTIFY THAT 1 AM PROPERLY REGISTERED AND,'OR ALTER,REPAIR.SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIORN A OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN, THE_aAOVE DESCRIBED RESIDF-INTIAL PROPERTY. ABANDON HOUC'E SEWER
SIGNATURE
OF PERMIT?' BACSF:FTiC TANKS Ljj
E pBACKFILL iS) CESSPOOLS
ROBERT A. WOOD
�"x VALIDATION SUPERVISING t41ECHANICAL ENGINEER
CK. M.D. CASH
LAL07 4 3 1-:4 N011 1,8 1 0 0 5.0 0-