HomeMy Public PortalAbout6025-6025 1/4 TEMPLE CITY BLVD_Sewer__ 6&E.6663 1254 APPLICATION FOR PERMIT 1
3 •
DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Department of County Engineer
County of Los Angeles TRESS
LDING
WM.J. FOX, COUNTY ENGINEER _
CASSATT D. GRIFFIN, SUP'T OF BUILDINGALITY
_ FOR APPLICANT TO FILL IN NEAREST
CROSS ST. -
LEGAL
DESCRIPTION_LOT N0. �`'S any v`:r OWNER
BLOCK TRACT ,. J ' MAIL
- N0. OF BLDGS, ADDRESS
.
SIZE OF LO7 ,.� C. t (; NO_W ON LOT
�OF .� / �"� CITY TEL.N0.
BUILDINGS f T L"r�
J _ DISTRICT NO. GROUP MAP
y_ 7 SK / PG
CONTRACTOR
ADDRESS '✓ CONNECTION DATA
CITY "- .. _V �V-TEL. NO � .;-.fjf' • STATION DEPTH
— �- STATE MANHOLE REFERENCE
REGISTRATION N0. € COUNTY UPPER LOWER
TYPE OF CONNECTION LENGTH FROM
NO, I DESCRIPTION OF WORK FEE Y. CURB P.L. M.L.70 P.L.
HOUSE SEWER CONNECTING TO I `
-� PUBLIC SEWER @ $ 3.50
HOUSE SEWER CONNECTING TO -
PRIVA_TE DISPOSAL SYSTEM L00 ___ — - -------- -
CONNECT ADDITIONAL BLDG. OR I e*.: CO. IMP.NO. SOB N0.
i WORK TO HOUSE SEWER_ LOO _ _
ALTER OR REPAIR EXISTING
SEVI ER ORDISPOSAL SYSTEM_ 1.00 — TRUNK PERMIT NO, ROAD PERMIT NO.
�j DISCONNECT AND ABANDON SEWER
STATE ENCROACHMENT
AND/OR DISPOSAL SYSTEM 1.00 PERMIT NO
O.
SEPTIC TANK SEEPAGE PIT OR
i PITS AND/OR DP.AINFIELDINDUSTRIAL 2.00 I WASTE APPROVAL.
~1 CESSPOOL DRYWEU y
SPECIAL CONDITIONS ONLY 2.00 I CHARGES
CONNECTIO.NCHARGE FEE -
OWNER'S PERMIT � il OO ---y---- -
Y
AUTHORIZATION TOTAL FEE ( Y', REIMBURSEMENT FEE
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S 5 GNATLRE
TO THE PUBLIC SEWER --�— -- -
NEW HOU5E SEWER I
SIGNED THIS DAY OF
CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK.
OWNERS AGENT Jam!
SEPTIC TANK, SEEP, PIT($)
AND/OR DRAINFIELD --
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL
AND STATE THAT THE ABOVE IS CORRECT AND AGREE 70 COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER, REPAIR,SEWER.OR
PLUMBING AND SEWERS. _ SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY RECISTERED AND/OR SEWAGE
DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF O HOUSE SEWER_
CALIFORNIA OR THAT I AM THE LEGAL OWNER,OF THE ABOVE .___.__
DESCRIBED RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS(
SEEP.P17(S) Cl CESSPOOLS❑_
SIGNATURE '
OF PERMITTEE
WILLIAM J. FOX, COUNTY ENGINEER VALIDATION
BY
By
DEPUTY r ,... PUTY
BY BY
e DE'I'TY DEPUTY