HomeMy Public PortalAbout5919 TEMPLE CITY BLVD_Sewer__ TEMPLE CITE
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'6A 642D = CE808 - 9/73 APPLICATION FOR PERMIT _Ll
COUNTY OF LOS,ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION FD
q Temple
City
q
1 N. em le C i(d B1.
Temple (,ity
FOR APPLICANT TO FILL IN CROSS ST. Las Tunas Dr.
LEGAL
DESCR PTION LOT NO. 231 'I OWNER b°U a G. Knox T^�
BLOCK TRACT 6561 MAIL 1524 Galaxy Dr.
ADDRESS 1C y tT'E�.�L may. q q
SITE OF LOT' NOW OONB LOTS CITY NeW Port Be 'F.�ahN0. 9 "'1 541
USE OF
BUILDINGS „paint
DISTRICT NO. GROUP MAP P CE5S BY
Zi6 Wstore i ;q �!" aBK P3^^t�
CONTRACTOR
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Square g� e�aylS�,ejwer Service
ADDRESS '9 2933 Maxson j7,.}4L�jY1!'� �+I /� COI�I�ECTIox DA'
El Monte TEL. NO. T'Y4-2020 STATION � 7 7 ` DEPTH
CITY Ld✓ / 7
Q Q }� (� # MANHOLE REFERENCE T UPPE
FV
LICENSE NO.. 128870 CLASS 4/"x'72 y�'ip Oma` .3 � LOWER
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM „-
1
PUBLIC SEWER SEWER CONNECTING TO - $7 00 q /1(1 Y. CURB P.L. M.L.TO P.L.
SEPTIC TANK,SEEPAGE PIT OR _ J• 6,7V / P.C.NO.
PITS AND/OR DRAINFIELD ® $10-00 CO.IMP.NO./ ,. ,I J08B NO.
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO.7 V
PRIVATE DISPOSAL SYSTEM $3.00
CONNECT ADDITIONAL BLDG.OR AFFIDAVIT WAIVER EASEMENT RECORD.INSTR.NO. DATE
WORK TO HOUSE SEWER @ $3.00
OVERFLOW SEEPAGE PIT.DRAINFIELD
EXTN.,CESSPOOL.DRYWELL. $5.00
HWY.OR STWIDENING
AL4ER,REPAIR OR A . .BANDON H SE �
SEWER OR DISPOSAL SY5TEM $3.00 CD
-.-_-3-00 STATE ENCROACHMENT
MANHOLE @ $7,00 PERMIT NO. W
INDUSTRIAL
WASTE APPROVAL N
OWNERS/� PERMIT $ 00 CHARGES
AUTHORIZATION I TOTAL FEE 1 181
00 CONNECTION CHARGE FEE
I 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 19_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS -
SEPTIC TANK.SEEP,PITS)
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WIT HALL COUNTY ORDINANCES AND STATE LAWS REGULATING I-7
PLUMBING AND SEWERS. CESSPOOL Q ❑
DRYWELL
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR.SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIF.C.RNIA OR THAT I AM THE LEGAL OWNER OF, AN INTEND TO DISCONNECT PLUG AND
REST DE IN, THE ABOVE DESCRIBED RESIDENTIAL PRO ERTY
J' ABANDON HOUSE SEWER
SIGNATURE 'd7 A,.n BACKFILL SEPTIC TANKS El
OF PEEL MTT4EE_ � a ___
SEEP.11TISI
❑ CESSPOOLS. '
VALIDATION CK. M.0. CASH
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