HomeMy Public PortalAbout6019 TEMPLE CITY BLVD_Sewer__ F-•86D83 fE•S8""
Sh APPLICATION FOR PERMIT`
,a E -
DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Department of County Engineer
County of Los Angeles -
JOHN A. LAMBIE, COUNTY ENGINEER JBUILDING
ADDRESS --`- y-- _
CASSATT D. GRIFFIN, SUP'T OF BUILDINGLOCALITY
FOR APPLICANT TO FILL IN NEARESTCROST, - ---------- -
LEGAi. OWNER
DESCRIPTION LOT NO, ,
'BLOCK TRACTMAIL: ADDRESS
NO. OF BLDGS.
SIZE OF LOT-,? NOW ON LOT CITY TEL. NO,
USE OF DISTRICT NO. GROUP MAP
BUILDINGS ` ,�•-�"' BK PG
CONTRACTOR I I
ADDRESS ._ -- .--s ----
CONNECTION DATA
�' -' :. - .-- _.__- _-----
STA'rt01d �,)` DEPTH
CITY SEL, N0. --- --- --- - -- -
- ----- ------- ------.---- MANHOLE REFERENCE �..' y, _ UPPER
❑ STATE -- - ----------- -_' ._._--_.._-'---- --�-
REGISTRATION NO. ❑ COUNTY
NO ! DESCRIPTION OF WORK EEE
TYPE OF CONNECTION LENGTH FROM
I HOUSE'EWER CONNECTING f0 y• C P.L. M.L. TOP 1
I PUBLIC SEWER $3..5 0 a ------- -�� ----------------
SEP IC TANK SEEPAGE PIT OR
_i PITS AND/OR DRAINFILLD (<r.' $3.90 I I __ -- -- --- -_- _ --.-
OVERFLOW SEEPAGE,PIT, DFAINFIELD ':� F C. N0.
EXTN.,CESSPOOL,DRYWELL,MANHOLE @ $2.001 CO. IMP NO. _j - JOB NO. _-
I HOUSE SEWER CONNECTING TO ., yy--
RIVATE DISPOSAL SYSTEM c( $1.00 i _ -.RUNK PERMIT NO ROAD PERMIT NO,3,4" w
l CONNECT ADDITIONAL BLDG OR ,, STATE ENCROACHMENT
l WORK TO HOUSE SEWER (`- $1.00 i r PERMIT NO.
i ALTER,REPAIR OR ABANDON HOUSE
-INDUSTRIAL.
SEWER OR DISPOSAL SYSTEM WASTE APPROVAL
I
CHARGES
__ CONNECTION CHARGE FEE
OWNER'S PERMIT5 — 1 OD - ---- ---- -
-----
REIMBURSEMENTFEE
AUTHORIZATION TOTAL FEE-- T ,3`
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- APPROVALS DATE I q P E C7 O R'S S I GN AT U RE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
70 THE PUBLIC SEWER. - NEW HOUSE SEWER
SIGNED THIS DAY OF____-_ 19=rCONNECT ADDITIONAL
--- -- — — -----
'OWNER OR >< - �
BUILDING OR WORK
—_�--- _ _-- _--_
OWNERS AGENT
_ EPTIC TANK,SEEP PIT(S)
ANDIOR DRAWN CLD �`---,-- ---- ----
I HEREBY ACKNOWLEDGE THAT HAVE READ THIS APPLICATIONI r---- _
CESSPOOL❑ DRYWELL 0
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER.REPAIR,SEWER OR ' --i--_--~_---
PLUMBING AND SEWERS, SEWAGE DISPOSAL SYSTEM
I
HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/Oft DISCONNECT PLUG AND �
LICENSED AS REQ'UIR'ED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE -- ------ -- ------ --I------�--- -__-. -
DESCRIBED RESIDENTIAL.PROPERTY. BACKFILL SEPTIC TANKS❑
SIGNATURE ,. a SEEP.PIT(5) ❑ CESSPOOLS L"
OF PERMITTEE
I
IOHN A'. L_AMBIE,COUNTY ENGINEER VALIDATION ROBERT A.WOOD, CIflEF PLBG, INSPECTOR
CK. M,9. q.{.CASH
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