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
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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/
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NEARES�r-
FS
FOR APPLICANT TO FILL IN CROSS ST.
r5CIPTION LOT NO, OWNER 11�,**k"l
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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
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