HomeMy Public PortalAbout6022-6024 TEMPLE CITY BLVD_Sewer__ 76AG42n,
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S a�e�63 I 1.5r, APPLICATION FOR PEI=
DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Department of County Engineer
County of Los Angeles BUILDINGp-
JOHN A. LAMBIE, COUNTY ENGINEFF?
CASSATT D. GRIFFIN, SUPT OF SUiLDING LOCALITY
-7
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
LEGL
DESCRIPTION LOT NO. OWNER
IM1IL
TRA E,DDR S
NO OF BLDG$, CITY TEL. NO.
SIZE OF 10-i
NOW ON LOT
USE Or
DISTRICT NO. GROUP MAP
r BK PG
CONTRACTOR
DATA
ADDRESS
fy� STATIOD-EPTH
TEL. NO. KT SM- NE REFERECE .
------- LOWER
REGiSTRATION NO,
LjI COUNTY
<
NO. !: DESCRIPTION OF WORK FEE
TYPE OF CONNECTION LENGTH FROM
HOUSES WER CONNECTING TO Y. CURB P.L. M.L. TO P.L.
PUBLiC,SEWER $3,501 R;z z
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DR;,INFIFI.D ((Cl $3.00
OVERFLOW SEEPAGE PIT,DRAINFIELD I 1 P. C. NO,
EXTN.,CESSPOOL,I)RYWEL.L,,TOI;I!�HO-L.E � $2- CO._IMP. NO. .._-_-.1.0BN 11,
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM (a S 1.0o TRUNK PERMIT NO. ROAD PERMIT NO.
CONNEC�T ADDITIONAL BLDG.OR STATE ENCROACHMENT
I'l (iit $ 1.0) �
WORK TO HOUSE SEWFR 1 10 'D PERMIT NO,
..OUSE PAi AE3AN DON!,i SE INDUSTRIAL
I SF ER OR DISPOSAL SYSTEM, 0 1
WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT 's I 1 00
ILo
AUTHORIZATION I REIMBURSEMENT FEE
I 'a, i
I HAVE AT THIS DATE A CONTRACT WITH THE HEREINNAMED CON- -APPROVALS DATE INSPECTOWSSIGNA-,ORE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER. NEW HOUSE SEWER
SIGNED THIS---.�, .--DAY 0F..
CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK
OWNERS AGENT-
SEPTIC TANK,SEEP,PIT(3)
ADDRrS
iiERF8Y ACKNOWLEDGE THAI I It" READ THISAPPLICATION CIZISSPOOLLI DRYWELLL-]
AND STATE THAT THE AHOVE 1S CORRECT AND AGREE TO COMPLY --7-
WITH ALL COUNly ORDINANCES AND STATE LAWS R I.G U LAY 1N G ALTER,REPAIR,SEWER OR
PLUMT,ING AND SEWERS, SEWAGE-DISPOSAL SYSTEM
HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR
NISCO
D
LICENSED ASTATE OF s REQUIRED BY LOS ANGELES COUNTY AND L i NECT PL.UG AND
CALIFORNIA OR THAT I W THE LEGAL OWNER OF THE ABOVE ABA-NDON-HOUSE- -SEINER
DESCRIBED RES!DENYIAL,�YOPERTY. BACKFiLL SEPTIC TANKS
SIGNATURE
SEEP. PiT iS)1-1 CESSP OLS D
OF'PERM[TTE
;OHN A. LAMBIE, Ce TY ENGINEER VALIDATION ROBERT A.WOOD, CHIEF PLEIG. INSPECTOR
M.