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HomeMy Public PortalAbout5948 TEMPLE CITY BLVD_Sewer__ E808 3-62 6A642D APPLICATION FOR PERMIT COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER -rm r BUILDING AND SAFETY DIVISION LDING It—, BUIL I JOHN A. LAMBIE, COUNTY ENGINEER BU' .B L '4 ADDRESS 7 COLEMAN W. JENKINS, SUPT. OF BUILDING LOCAL[TY7/ _ NEARES�r- FS FOR APPLICANT TO FILL IN CROSS ST. r5CIPTION LOT NO, OWNER 1­1�,**k"l -A'la'.i' BLOCK TRACT ADDRESS NO. OF BLDGS, SIZE OF LOT NOW ON LOT CITY TEL. NO. 'X� USE OF I -BUILDINGS DISTRICT NO. GROUP1 SK MAP P G PRC I'CIESSED BY CONTRACTOR L2 ADDRESS 2 CONNECTION DATA CITY f TTAToftDEPTH ✓ EL. NO � STA rE 2 LIC Z MANHOLE REFERENCE LICENSE NO. CLA SS LOWER NO. --DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM HOUSE SEWER CONNECTING TOY. CURB P L., M.L.TO P.L. PUBLIC SEWER $5.00 1 i�(-� P.C.NO. 0 SEPTIC TANK.SEEPAGE PIT OR -4 CO.IMP-NO I' - C, JOB NO. u PITS AND/OR DRAINFIELD slo.00 -W TRUNK PERMIT NO. ROAD PERMIT NO. w OLFSE�E;WERCON CONNECTING PRIVATE DISPOSAL SYSTEM @ S3.00--j'---- 0 CON -NJECTADDIT'IONALTC- DG OR --- --- AFFIDAVIT 1, wAiVIR 1ASEMENT RECORD.TNSTR. No. DATE WORK TO HOUSE SEWER $a-oo Lu OVIERF�OWS�EFPAGIE PIT.DRAINFIELD 0- i EXTN CESSPOOL.DRYWELL,MANHOL-E @ $5.00 E:`9 _,— - REPAIR- -ABANDON--- - -- --—----r--!- -- HWY. OR ST.WIDEN]NG ALTER, PAIR OR - HOUSE z SEWER OR DISPOSAL SYSTEM @ S3,00 STATE ENCROACHMENT PERMIT NO. INDUSTRIAL WASTE APPROVAL, CHARGES OWNERS PERMIT $ 21 00 AUTHORIZATION 1--TOTAL FEE -7 CONNECTION CHARGE FEE REIMBURSEMENT FEE IHAVE: AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- TRACTOR R ACTOR T 0 CONNECT THE ABOVE DESCRIBED EXISTING-DWELLING To THE PUBLIC SEWER. APPROVALS DATE INSFIE TOWS.SIGNATURE SIGNED THIS-DAY OF--19- OWNER OR NEW HOUSE SEWER OWNERS AGENT_,_ - "CONNECT ADDITIONAL ADDRESS BUILDING OR WORK SEPTIC TANK.SEEP,PIT(S) IHEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING PLUMBING AND SEWERS. CESSPOOL 1:1 DRYWELL [:1 IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWER OR LICENSED AS REQUIRED By T L OS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM CALIFORNIA ALIFORN I A OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO D-ISCONNECT PLUG AND RESIDE IN, THE ABOVE. DESCRIBED RESIDENTIAL PROPERTY, ABANDON HOUSE SEWER SIGNATURE BACKFILL SEPTIC PERMITTEE TANKS E3 SEEP.PIT S) ❑ CESSPOOLS Or VALIDATION-,, JACK R. ALLEN SUPERVISING MECHANICAL ENGINEER CK. M.O. C A 5 H 7 7 4 1,13 DX23 13 D 7,rj Qj-