HomeMy Public PortalAbout6026 TEMPLE CITY BLVD_Sewer__ ]DEPARTMENT OF COUNTY ENGINEER SEWER--SEWAGE DISPOSAL 1
-D.IVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES BUI NG ✓
WILLIAM J. FOX, COUNTY ENGINEERADDRESS
FOR APPLICANT TO FILL IN _ LOCALITY
BUILDING ' NEAREST
ADDRESS i ,; ~,.�.. CROSS ST. s ��/�✓
LOCALITY DISTRICT NO. "3/ERt1tt'N0. PERMIT NO./c
NEAREST A tF j f •?���/ / J
CROSS ST. if
RECEIVED BY Ready for Inspection DAT LSS ED
OWNER ,
MAIL ��V� USE ZON OCCUPANCY BK PG
ADDRESS '
CITY 6 TEL.NO. .G;.•-
CONTRACTOR CO.IMP.NO.
ADDRESS rTL� JOB NO.
CITY
i E NO. TRUNK PERMIT W0.
REGISTRATION N0. �! r( COUNTY ROAD PERMIT N0.
LEGAL / STATE ENCROACHMENT
DESCRIPTION LOT N0. Z2 Z07 —^
_PERMIT NO.
BLOCK TRACT _ r' INDUSTRIAL °---
WASTE APPROVAL
SIZE OF LOT . ry NOW ON LOTS CHARGES
USE OF
BUILDINGS CONNECTION CHARGE FEE
NO. DESCRIPTIVIN OF WORK FEE
HOUSE SEWER CONNECTING TO REIMBURSEMENT FEE
PUBLIC SEWER @ $ 3.50 RECEIPT NO. I DATE I BY
HOUSE SEWER CONNECTING TO
_ PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.OR EXCEPTION RECORDED
f WORK TO HOUSE SEWER 1.00 G
ALTER OR REPAIR EXISTING NO' I DATE BY
SEWER OR DISPOSAL SYSTEM 1.00_
DISCONNECT AND ABANDON SEWER
_ AND/OR DISPOSAL SYSTEM I.00 CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR _
PITS AND/OR DRAINFIELD 2.00 STATIONe 1 �J�z DEPTH
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 2.00 MANHOLE REFERENCE
_ UPPER _ . .-LOWER
TYPE OF CONNECTION LENGTH FROM
OWNERS PERMIT $ ( Y, CURB P-L..._-.,- •IW:L.TO P.L.
AUTHORIZATION f TOTAL FEE f `
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING, APPROVALS INSPECTOR'SSICNATURE DATE
DWELLING TO THE PUBLIC SEWER
SIGNED THIS..........--.__DAY NEW HOUSE SEWER
CONNECT ADDITIONAL
OWNER 0R OWNERS AGENT BUILDING OR WORK
_.
p SEPTI TANK,SEEP.PIT(S)
ADDRESS----L>_.t._4 , __... ...... _. . 'AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT 1 HAVeREAD THIS APPLI- CESSPOOL 0 DRYWELL
CATION AND STATE THAT THE ABOVE 19 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 REGISTERED DISCONNECT PLUG AND
ANO/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOUSE SEWER
AND STATE OF CALIFORNIA 0 THAT I AM THE LEGAL OWN-
ER OF THE ABOVE DESCR(BEII RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS E]
SEEP.PIT(S)E] CESSPOOLS
SIGNATURE ."•�' v'
OF PERMITTEE__....... -_---•y.:� ._:_.... ._..._.;r...--__-_..______..,
76A642A 66=17/ 3