HomeMy Public PortalAbout5936-5936 1/2 TEMPLE CITY BLVD_Sewer__ 'fl'6A 6420 -CE808-10-71 APPLICATION FOR PERM1 -.
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION FC
y
FOR APPLICANT TO FILL IN
--- - - - -
LEGAL___ S l•^ ---
DESCRIPTION LOT NO. C._ _ OWNER
MAIL -
BLOCK TRACT ,;, ^ jr ADDRESS
NO. OF SLOGS. d y of /P ✓�
SIZE OF LOT NOW ON LOT CITY T.L. NO.
USE OF
BUILDINGS DISTRICT N0. GROUP B K "AAP PS PROCESSED BY
.-'
CONTRACTOR •lam ''r' ;,;.yl. 2 J .J
ADDRESS L' > CONNECTION DATA
,,t STATION ri„y J > DEPTH
CITY /Gni- TEL NO,[STATELC
/r✓, �e' ' --�
C` MANHOLE REFERENCE
LICENSE NO, ?'� ��'� GLASS
NO. DESCRIPTION OF WORK FEE TYPE OF CONNECTION LEN G7HlFRO
HOUSE SEWER CONNECTING TO ,,((� �+ Y. CURB 1f PL. ." M.L.TO P.L.
PUBLIC SEWER @ $7.00 b L�
SEPTIC FANK.SEEPAGE PIT OR P.C.NO.
PITS ANDOR DRAINFIELD @ $10.00 CO.IMP.NO. JOB NO.
HOUSE SEWERCONNECTING TO TRUNK PERMIT NO. ROAD PERMIT NO. CL
PRIVATE DISPOSAL SYSTEM @ $3.00 0
CONNECT ADDITIONAL BLDG,OR AFFIDAVIT I WAIVER I EASEMENT RECORD.INSTR.NO. DATE U
WORK TO HOUSE SEWER @ $3.00
OVERFLOWS—EE PAG E PIT.DRAINFIELD
EXT N..CES SPOOL,ORYWELL, $5.00 HWY.OR ST.WIDENING ,.q 0
ALTER.REPAIR OR ABANDON HOUSE 1,✓ ,.�.� .,.}'' I—
SEWER OR DISPOSAL SYSTEM @ $3.00 _ STATE ENCROACHMENT f' - W.
MANHOLE-- $7.00 PERMIT NO. C.
--- INDUSTRIAL
H
WASTE APPROVAL J,
OWNER'S-1 PERmrr $1 31 00 CHARGjfS
AUTHORIZATIONJ TOTAL FEE VJ C 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
TO THE PUBLIC SEWER_. - APPROVALS D E a INSPE OR'S SIGNATURE
SIGNED THIS, ,�-` DAY OF 19_ •a
OWNER OR I .J NEW HOUSE SEWER -
OWNERS AGE T - CONNECT ADDITIONAL
ADORES.
�✓ .i.-' BUILDING OR WORK
� -
` SEPTIC TANK,SEEP,PIT(S)
i L -
HEREBY A NOWEDG HAT 1 HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE HAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS. CESSPOOL ❑ 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
CALIF0RNIA OR THAT I.SAM THE LEGAL OW7R OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN. THE ABOV LOESCRI�.ED ESIDp TIAL PROPERTY. ABANDON HOUSE SEWER
SIGNATUREOF PERM?TTE6 __ BACKFILL SEPTIC TANKS ❑ t; y.'f
SEEP.PIT(S) �' ESSPOOLS',Q
VALIDATION CK. -.0- ' SH
76A 642U APPLICATION FOR PERMIT
7fi,A
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING -
JOHN A. LAMBIE, COUNTY ENGINEER ADDRESS
COLEMAN W. JENKINS. SUPT. O>+ BuILDINGLOCALITY
r ;V
NEAREST r �
78LOCKI
R APPLICANT TO FILL IN CROSS Sr �✓/L'`
(PRINT O R TYPE ONLY)
--"- "' - --'LOT NO. 0 OWNER A�L/t''t1:IJ r;�� c�• de yam'®MAIL , 7_. �TRACT " ADDRESS yid
SIZE OF LOT NOW ON LOT ) CITYl�t �:,���,/, TEL. NO. � `'b`-Xn' y0
USE OF
BUILDINGS j - ,•s - :: •. t{;,� D;;STRICT N?.l GROV I f_LASS 'AAP PROCESySE.C,_p T'
✓` J�" 9J d
CONTRACTOR y_.c3� _�`+` � S° r P'i..:v.���_�_,—_- �'' '` IJ 1...•j i'� '1./ --
ADDRE5S 1 _ ,�'; v ;�..ti�,...., _ C_ONNE_CTIO_N_DATA --_� ---_---
7. ` STATION DEPTH
CITY k _' -1"'a.Si-_sA�.- TEL NO. { 3E-
_ UPPER
STATE .. '''T LIC f MANHOLE REFERENCE --- --
LICENSE NO. Tfr_.�' GLASS ;�.y LOWER
NO. DESCRIPTION OF WORK FEE___ _ TYPE OF CONNECTION LENGTH FROM
R
HOUSE SE—WE CONN ECT INC TO Y. CURB P.L. M..L.TO PL.
PUBLIC SEWER @ $5.00
,_-_...-___________. _- P.C.NO.
SE?TIC fANK,SEEPAGE PIT OR .JOB NO
PITS ANDf OR DRAINF'IELD !610.00 CO.IMP.NO.
HOUSE$EWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM @ $3.00 TRUNK PERMIT NO. ROAD PERMIT NO.
- /2
-__.- 'i w
CONNECC T ADDITIONAL P.
BLDG. OR FF{DA V{T A{YC4 i EASEMENT� RECORD.{NSTR.NO. DATE
WORK TO HOUSE SEWER L- $3.00 '�9
__ ____ _--.-_. - ".._._-....._..
bVERF_LOW SEEPA G£PIT.DRAtNFtELtl
EXTN..CESSPOOL.DRYWELL.MANHOLE @ $5.00
1
ALTER.REPAIR OR ABANDON HOUSE HWY.OR ST WIDENING SEWER OR DISPOSAL SYSTEM @ $3 00 Fc,
- _ _ -�- --- -'-' ---- e
STATE ENCROACHMENT J
I
PERMIT NO _ C„
INDUSTRIAL
WASTE APPROVAL z
--- CHARGES
LAH
WNERS PERMIT $1 00 CONNECTION CHARGE FEE
HORIZATION TOTAL FEE . --- -----
VE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- REIMBURSEMENT FEE .
TOR TO CONNECT THE ABOVE DE
EXISTING DWELLING --- APPROVALS To
HE PUBLIC SEWER. AC -Y DATE INSPECTOR'S 51GNATURE
ED THIS DAY OF 19_ --- "— —OWNER OR NEW HOUSE SEWER
ERS AGENT -.-- CONNECT ADDITIONAL
BUILDING
� -
BUILDING OR WORK
ADDRESS-__—_ -
-T - SEPTIC TANK,SEEP,PIT(S)
IEREBY ACKNOWI_EV(:E THAT I HAVE READ TH15 APPLICATION AND'OR DRAINFIELLY
STATE THAT
THE ABOVE 15 CORRECT AND AGREE TO COMPLY
ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
cING AND SEWERS. CESSPOOL ❑ CRYWELLHEREBY CERTIFYTHAT I AM PROPERLY REGISTERED AND{OR ALTESEWER OR
N5E0 AS REgUIREO BY LOS ANGLES COUNTY AND STATE OF 5E\V AGE DISPOSAL SYSTEMf'ORNIA OR THAT 1 AM THE 1_EGAL OWNER OF, AND INTEND TODISCONNLCT PLUG AND
DE IN, THE AB VE DESCRISEQ,RES�ENTIAL PROPERTY. ABANDON HOUSE SEWER
ATURE f� t }y L;PER MPTTE Y �� y frw3v 'y` Y"_ __________ BACKFILL SEPTIC TANKS
SEEP.PIT(S) ❑ .CESSPOOLS I]i
VALIISATIONJACK R. ALLEN
7_
_ :._v,
-
"A SUPERVISING MECHANICAL ENGINEER
CK. M.O. t CASH