HomeMy Public PortalAbout5946-5946 1/2 TEMPLE CITY BLVD_Sewer__ 76AE-6C3 Iz,sa
S APPLICATION - FOR PERMIT ],
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DIVISION OF BUILDING ANIS SAFETY SEWER-SEWAGE DISPOSAL
Department of County Engineer
County of Los AngelesFS
BUILDING ,yr
ADDRESS
WM.J. FOX, COUNTY ENGINEER — a —+ � F�
CASSATT D. GRIFFIN, SUPT OF BUILDING LOCALITY¢ �- %'t•', _;;,r
FOR APPLICANT TO FILL IN NEAREST r
CROS§ST.
LEGAL - �, ------.:— _�
—DESCRIPTION LOT NO ,✓' r„f .-'/ OWNER
-BLOCK TRACT ri 4 y BIAIL
ADDk ESS
NO. OF BLDGS.
SIZE OF LOT - NOW ON LOT CITY TEL. NO.
USE OF
6UI.LDINGS� _—_ DISTRICT NO. i GROUP BK MAP PG
CONTRACTOR ... %'. b:".� y --:» .c'`..-,f :, Ty._.
ADDRESS,, 3c� � � "?� .`��✓,*��� s~ CONNECTION DATA
CITY NO , i,'J._`sr't.,i$+"n STATION -`. 0EPrH
(}''STATE -r - —M,ANHOLE P,EFERENCE
REGISTRATION NO. COUNTY UPPER_«
NO. ! DESCRIPTION OF WORK FEE TYPE OF CONNECT;ON LENGTH FROM
f`I .HOUSE SEWER CONNECTING TO
J' i PU84!G S�WE:R $ 3._5_0
1^HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM _1.00_1 _
CONNECT ADDITIONAL BLDG. OR CO. IMP. NO y
_ t OaK TO HOUSE SEWER 1.00 JOB. NO.
ALTER OR REPAIR
-`. J.�
SEWER. OR D'Sr0 AL YSTEM — -TRUNK PERMIT NO. ROAD PERMIT NO. -
�I DiS;k_)NNr_Ci AND ABANDON.SEVi E:R j
._ P L'�CR DISPOSAL SYSTEt-0 1.04 I �� p. STATE ENCROACh4MENT
PERMIT NO.
SE r!C 1ANK,SEEPAGE PIT OR -- -" - -
I i .AND/OR DRAINFIELD 2,00 iNDUSTRIAL of ._ _ jv
WASTE APPROVAL
S C:h.L v h: TICK. ONLY 3.00 CHARGES
i
-
'— —�- '---
CONNECTION CHARGE FEE
OWNER'SPERINUT S ii 00
AUTHORIZATION ,I TOTAL FEE '~ REibIBURSEMrNT FEE_
---
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I HAVE THIS DATECONTRACTED WITH THE HEREIN NAMED CON-
T
ON- APPROVALS DATE INSPECTOR'S SIGNATURE
TRACHED U IC SECT THE ABOVE DESCRIBED EXISTING DAE L�SwG .� -
TO THE PUBLIC SEW'E7, T ---- ---NS
SIGNED THIS DAY OF i9 NEW Hoo SL v a
OWNER OR - !`�' �E 1' CONNECT ADDITI ANAL
OWNERS AGENT
ii..,f w,�'""C.'"' BUILDING OR WORK
SEPTIC TANK, e.EEP, PIT(S)
y
ADDRs.5S__--� — _ ----_ AND OR DRAINNELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL 0 DRYWE.LL
AND STATE THAT THE ABOVE IS CORRECT AND AGREE 70 COMPLY
F'YITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER, REPAIR,
SE'4YER OR
PLU?,",c�iN3 AND SEWERS. SEWAGE DISPOSAL SY_STE__M___ _
1 rcREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/`OR DISCONNECT PLUP. AND i
LICE.NS£D AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF !.�
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF .THE ABOVE __ABANDON HOUSE SEWER EE .�.... —._.
DESCRIBED RESIDENTIAL,PROPERTY. BACKFILL SEPTIC TANKS fJ
_ - SEEP.PIT(S) Q CESSPOOLS C1
SIGNATURE - ....-_..._._
OF PERMITTEE '.--
WILLIAM J.FOX, COUNTY ENGINEER VALIDATION
By T,0,2' 9 4"'S APR 4 4 `'i'.5 0BY
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DEPUTY DEPUTY
BY BY
DEPUTY ,''.r., - ' DEPUTY