HomeMy Public PortalAbout6020 TEMPLE CITY BLVD_Sewer__ DEPAIVrMENT OF COUNTY ENGINEER, SEWER-SEWAGE DISPOSAL
D13A SION OF BUILDING AND SAFETY _ PERMIT PPLICATION
COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER BUILDING _ - -
ADDRESSBUILDINIP , ♦ -F`
FOR APPIIICAI'b TO FILL IN, � oc f , ¢
ADDRESS Lg # /�✓ ROSS 3T. T` r F g
LOCALITY t. �.� f 1DISTRICT NO. SERIAL NO. PERMIT NO.
NEAREST A -- r/'� S
CROSS ST. � —
_
RECEIVE,(�1 BY Ready for Inspection DAT ISSUED
OWNER
MAIL
ADDRESS _/ f j /rte t;, • t� SE ZONE I OCCUPANCY BK PG
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CITY nr A �TEL.NO. ` � -� ,✓ ^ "
CONTRACTORl�Ri
CO.IMP.NO.
ADDRESS 0 C. ''
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CITY 4 f t TELAO.j�. N TRUNK PERMIT N0.STATE
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REGISTRATION NO. ,t;( �] COUNTY a�
ROAD PERMIT N0. -� AP.
LEGAL Q m / STATE ENCROACHMENT
3 26
DESCRIPTION " LOT N� C� 6R
- PERMIT N0.
BLOCK ,.... TRACT INDUSTRIAL
WASTE APPROVAL
SIZE OF LOT ",,, X f? N0.OF BLDG6.
�+ NOW ON LOT CHARGES
USOF
BUILDINGSCONNECTION CHARGE F E
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO
--- REIMBURSEMENT FEE
k PUBLICSEWER 0 $ 3.50
_i-__._. _ ___..._— RECEIPT N0. GATE I BY
HOUSE SEWER CONNECTING TO
PRIVA TE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.OR EX PTION R OROED
WORK TO HOUSE SEWER 1.00_ _
ALTER TR REPAIR EXISTING NO DAT!�S BY
SEWER OR DISPOSAL SYSTEM_ 1.00
DISCNNECT AND ABANDON SEWER
AHD/OR DISPOSAL SYSTEM 1.00 CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR /� _0e —
— PITS P. DRAtNFIELD 2.00 STATION �el' DEPTH
CESSPOOL—OL—DRYWELL
SPECIAL CONDITIONS ONLY 2.00 MANHOLE REFERENCE r
UPPER ' tiDWER-
TYPE OF CDNNECTI0N LENGTH FROM
OWNERS PERMIT $ --w-- CURB F-.-L. M.L.To P.L.
AUTHORIZATION , TOT— AL FEE
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING
DWELLING TO THE PUBLIC SEWER APPROVALS INSPECTOR'S SIGNATURE DATE
SIGNED THIS.-... ... ..._..DAY OF._ ..............................19., . :; NEw HOUSE SEWER
OWNER OR �j t CONNECT ADDITIONAL
OWNERS AGENT 1 - �e Lt BUILDING OR WORK
/ �4' " 1 . SEPTIC TANK.SEEP.PIT(S)
ADDRESS JGt..- ,��-i-, n.�"=. ...... ..-- «ae ,-_ AND/OR GRAINFIELD
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIA APPLI- otESSPOOL E3 DRYWELL E]
CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER.REPAIR,SEWER OR
REGULATING PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTEREDDISCONNECT PLUG AND
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOUSE SEWER
AND STATE OF CALIFORNIA OR THAT I AM THE LEGAL OWN-
ER OF THE ABOVE DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS J
`
SIGNATURE SEEP.PIT(S)o CESSPOOLS G
S"?
OF PERMITTEE.-._
76AG42D 663 1/53