HomeMy Public PortalAbout5957 TEMPLE CITY BLVD_Sewer__ 11 mc� "1701111"Kfp
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:ze0a ° APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS
JOHN A. LAMBIE, County Engineer `--
CASSATT D. GRIFFIN, Supt of Building LOCALITY.
NEAREST `–
FOR A 'PLIANT TO FILL IN CROSS ST.
DE5CRiPTIONLOT NO - OWNER
BLOCK TRACT ,�' MAIL --
_ - ADDRESS
NO.OF BLDGS.
_SIZE OF L.OT NOW ON LOT CITY TEL.. N0.
USE OF� _
BU1LD.NGS OISTRIC� t1U GROUP MAP PROC.:SS;DBY
-- _; – -- ---- – BK PG
CONTRACTOR p
ADDRESS - CONNECTION DATA
CITY, TE L.N O. STATION DEPTH
STA'T'E MANHOLE REFERENCE, UPPER�
REGESTRATION NO ._._ ___�, COUNTY
NO. DISC !PT!^1t OF W RGA–}( ' FEE
aUBL4'SFsY R CONNECTING TO
PU L CS;=rYER
SEPV TANK SEEPAGE PIT ORATYPE OF CONNECTION y LENGTH P,
F RON y
PITS NDi OR DR A'.NFIELD @ S3.00 Y° CJRFt M.L.TO L.,
OVERFLOW SEEPAGE PIT, DRAINFIELD
EXTN.;CESSPOOL.DRYWE'LL @ $2.00
HOUSE SEW KR CONNECTING TO P.C.NO.
F_ PRIVATE CI POSAL SYSTEM @ $4,00 CO. IMP.N0. fOB NO.
CO NEC
ADJ'TIONAL BLDG.OR
G N
O0 ROAD PERMIT NO.
WORK,D hO' SE SEWER 0? $4.00 TRUNK PERMIT _
^rA T-ER, eLik 4 ORB ANOON HOUSE STATE ENCROAteIM.ENT _.s
S_4,ErT GF Diu?:OSAL SYSTEM.- @ $1.00 111. PERMIT NO.
T-1 —' INDUSTRIAL -
�F— WASTE APPROVAL
CHARGES
OWNER'S PERMIT $ 2100 CONNECTION CHARGE FEE
AUTHORIZATION I TOTAL FEE I i REIMBURSEMENT FEE
1 HAVE AT THIS DOTE A CONTRACT WITH THE HEREIN NAMED .CON- pay
TRACTOR TO. CONNECT THE ABOVE DESCRIBED EXISTING DWELLING - APPROVALS l DATE I INSPECTOR'S S7GNA1'URE.
I'0 THE PUBLIC SEWER.
SIGNED THIS DAY ONEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK _
ADDRESS–_ SEPTIC TANK.,SEEP.PIT(5)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE TI4AT I HAVE READ THIS APPLICATION
_AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL f-I _
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAID SEWER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY" CERTIFY THAT I AAI PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OP ABANDON HOUSE SEWER
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIAL PROPERTY, BACKFILL SEPTIC TANKS n
SIGNATURE
SEEP.PIT(S) O CESSPOOLS [] _
- "-OF PERMITTEE. :.
F VALMATION ROBERT A. WOOE)
CIL M.0. CASH SUPERVISING MECHANICAL ENGINEER