HomeMy Public PortalAbout6030-6030 1/2 TEMPLE CITY BLVD_Sewer__ 3 E-61•66173 71.55
i APPLICATION FOR PERMIT1
8.E
DIVISION OF BUILDING AND SAFETY SEWER—SEWAGE DISPOSAL
Department of County Engineer
County of Los Angeles BUILDING ;, s
ADDRESS_..___ .. .M-'+ � f -'_" -=_...�' _:✓';c;' _
JOHN A. LAMBIE, COUNTY ENGINEER -- - _
5 CASSATT 1). GRIFFIN, SUPT 0,BUILDING LOCALITY �• `��' �^�-
FOR APPLICANT TO FILL IN CROSS ST.
LEGAL
t�t --- f - .,— -------- '— -
DESCRIPTIONLOT NO J `� ,JF „!:. ' '`: GWNER
BLOCK TRACT s .X t� MAIL .
s!.•�-.1� ADDR ESS%-..»
NO. OF BLDGS.
SIZE OF LCT,�, NOW ON LOT CITY TEL. N0,
USE OF ✓ r' -
BUILDINGS " ✓' .,. DISTRICT NO. GROUP MAP
BK Pc
CONTRACTOR
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CONNECTION'DATA
ADDRESS ,
,.. STATION zi
DEPTH
TEL NO. /.r - ->- - g----- ----(.PPER
MANHOLE REFER;=NCE .__
[ STATE LONIEI?
REGISTRATION NO. ,;' . '.fig [] COUNTY --� ---�-- --T-�- --._ .---
No. ! -DESCRIPTION Or WORK FEE - - --------
---' - --- - - --•-- -- TYPE OF CONNECTION LENGTH FROM
HOUSE SEINER CONNECTING TO
_ PUBLIC SEWER - @ ,$3;50
SEPTIC TANK SEEPAGE PIT OR Y•-_ __CURB _P L. M.L.TO P,L.
i_ PITS AN_D'OR DRAINFIELD (n) $3.00 . _.. yam..
--i OVERFLOW SEEPAGE PIT,DRAINFIELD - --�^ �- -P E- • r __ .r -� „-
XTN-,CESSPOOL,DRYWELL,MANHOLE Cgs $2.00 CO. IMP..NO. JOB Nom. - _�-..a,;�;?X_
1 HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM r2 $1.00 f TRUNK PERMIT NO. _ _ROAD PERMIT NO.
CONNECT ADDITIONAL BLDG.OR j STATE ENCROACHMENT
WORK TO HOUSE SELLER (i I. Lk
-' $-O�� I C� PERMIT N0.
ALTER,REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM :$1.00
---J'- ----- - --- ------ - ---�-----�--- WASTE APPROVAL
---------_---.- - CHARGES
__- 1-- CONNECTION CHARGE FEE- -- -_--_------J --OWNER'S PERMIT PERMIT S 1 00 - - - —..— _ -- --
AUTHORIZATION TOTAL FEE-- REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. APPROVALS i DATE INSPEC70R'SS1Gf•1.ATURE
TRACTOR TO CONNECT THE.-ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER,,,- --�` NEW HOUSE SEWER i
SIGNED THIS— DAY - 19 -- - --- --
_:- CONNECT ADDITIONAL
OWNER OR �'_: BUILDING OR WORK
OWNERS AGENT_ +
SEPTIC TANK,SEEP,PIT(S)ADDRESS— .
.f'` C r'` X-f AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL C; DRYVIELL(�
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO 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 REGISTERFD A.NDIOR DISCONNECT PLUG AND
LICE NSLD AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE ABANDON MOUSE SEWER -_— -
DESCRIBED RESIDENTIA OPERTY BACKFILL SEPTIC TANKS 0
SIGNATURE �
SEEP. PITS) a CESSPOOLS[]
�� --� '�'�'t.;�.' � �
OF PERMITTEE I
I
[OHN A. LAMBIE. COUNTY ENGINEER VALIDATION ROBERT A.WOOD,CHIEF PLBG. INSPECTOR
CK. M.
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