HomeMy Public PortalAbout5926 TEMPLE CITY BLVD_Sewer__ IGA6420
E-663 SSSS APPLICATION FOR PERMIT 1
5&6.66
DIVISION OF BUILDING ANIS SAFETY SEWER--SEWAGE DISPOSAL
Department of County Engineer
County of Los Angeles BUILDING ,
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESSA el
CASSATT D.GRIFFIN, Sup'T OF BUILDLOCALITY
SNG awe ,.-�a:_.
_ FOR APPLICANT TO FILL INCROSS ST. `` `
LEGAL
-DESCRIPTION LOT NO. 9 !' - OWNER .,
ppp ,y -
BLOCK TRACTMAIL'sg _ _ADDRESS
X�110. OF BLDGS.
SIZE OF LOT ,.�''I�'�t;>�f NOW ON LOT CITY TEL. N0.
USE OF �'-
_BUILDINGS _ der;-` - DISTRICT N0. I GROUP MAP
-- I BK PG
CONTRACTO
ADDRESS , .«✓ CONNECTION DATA
STATIOF! � �4> DEPTH
tp
_CITY � - TEL. NO. _✓ - �r MANHOLE REFER ✓ ER�" �`"5- STATEREGISTRATION NO. 1J COUNTY
NO. I DESCRIPTION OF WORK FEE ------- ----. ---- --
-_ TYPE OF CONNECTION_tea LENGTH FROM
HODS£SEWER CONNECTING TO I .w Y. CUPP, t>P�.L: t3 M.L.70 P.L, s'
I PUBLIC SEWER - C $3.50 I _ - -
--- - — —
_ ISEPTIC TANK,SEEPAGE PIT OR -
_NTS AND/OR DRAINFIELD_ _ _ _�� $3.00 ------- --� — —.-.- -
OVERFLOW SEEPAGE PIT DR4INFIELD - P. C. NO.�
EXTPS.,CESSPOOL,DRYWELL,MANHOLE (q1S 2.00 _C0. IMP.NO. JOB NO, _
I HOUSE SEINER CONNECTING TO --�—�_-_— ---- _--
PRIVATE DISPOSAL SYSTEM, ((t� $I.CO TRUNK PERMIT NO. ROAD PERMIT NO.
CONNECTADDITIONALBLDG.OR STATE ENCROACHMENT
WORK TO HOUSE SEWER (u7 $1.00 I __ PERMIT NO.
ALTER,REPAIR OR ABANDON HOUSE I INDUSTRIAL
SEWER OR DISPOSAL SYSTEM -- --_ ( $i.C) !.-_--T.---_ - WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
00
OWNER'S PERMIT -- --�. -__..-- -----------._ _,_
� � 1
--- _--- ---- REIMBURSEMENT FEE
AUTHORIZATION TOTAL FEE
I HAVE AT THIS APPROVALS IS DATE A CONTRACT WITH THE HEREIN NAMED CON- __ ._ -- --___-__-_____.——DATE iNSPECTOR'SSIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXfSTING DWELLINGi
TO THE PUBLIC SEWER. NEW HOUSE SEWER I � -
--
SIGNED THIS AY GF._ _ --I9. CONNECT ADDITIONAL
r
OWNER OR f„j' -BUILDING OR WORK
OWNERS AGENT___ SEPTIC TANK-SEEP PIT(SI _ 1
ADDRESS___._--...---- ---- ANWOR
1 HEREBY A. KtOVL.EDGZ THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRfci'ELL❑ '
,HE ABOVE IS CORRECT AND AGREE TO COMPLY I
AND STATE THAT __t_._._------------
WJTH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER OR
PLU,M,BiNG AND 5E4VERS. -
SEiVFlGE DISPOSAL SYSTEM _
I
HERBY CERTIFY THAT I AM PROPERLY REGISTERED ANDD OR DISCONNECT PLUG-AND
LiCEN'ED AS REQUIRED LOS ANGELES COUNTY AND STATE OF
CALIFORNIA OR 'M 4tl
" M THE LEGAL OWNER OF THE ABOVE ABANDON HOUSE EWER — -
DESCRIBEDRE !DEN'�.4OPERTY. BACKFILL SEPTIC TANKS[j
fid. SEEP.P 1 31 i_1 CESSPOOLS(-S '.
SIGNATURE - --- -_-._ —._.--I
OF PERMITTEE g ad --_---_--
JOHN A. LAMB , COU Y ENGINEER VALIDATION ROBERT A. WOOD, CHIEF P'L6G. INSPECTOR
CASH
1 45
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