HomeMy Public PortalAbout6032 TEMPLE CITY BLVD_Sewer__ - PAli1'=NT OF'COU11T'IrY EN(IIVEES_
StWER—SEWAGE DISPOSAL
DIVISION .OF BUILDING AND SAFETY PERMIT APPLICATION
COUI*= OF LOS A11TGWAS
BUILDING /
WILLIAM J. ;FOX. COUNTY ENGINEER I ADDRESS �0 �
7,r/11 b
FOR APPLICANT TO FILL N LOCALITYBUILD
-ADDRESS •�® CROSS SEEST.
LOCALITLZZ., DISTRICT NO.. SERIAL N0. PERMIT NO.
NEAREST A 6y 29,R'S
CROSS ST. . RECEIVED BY. Ready for Inspection �j DATEISSUED
OWNER ,eg .MAIL
ADDRESS-, USE ZONE OCCUPANCY BK MAP PG
CITY '. j TEL:NO. aa I 415 /, I A/0
CONTRACTOR
CO.IMP.N0. F7 w-
ADDRES ��� ��� � JOB NO.
CITY^ o � TEL.NO. TRUNK PERMIT N6.
ISTATEREGISTRATION NO. � -, CO NTY
ROAD PERMIT NO.
LEGAL ' STATE ENCROACHMENT - r
DESCRIPTION LOT NO��. p,��j ®� PERMIT NO.
BLOCK TRACT - ! WASSTRIAL
TE APPROVAL
SIZEOF LOT NO.OFNOW ON LOTS CHARGES
USE OF
BUILDINGS r j��yJ�0CONNECT CHARGE FEE
NO. DESCRIPTION-OF WORK.' FEE
HOUSE SEWER CONNECTING TO % REIMBURSEMEN E
PUBLICSEWER 0 $ 3.50 - RECEIPT NO. DATE I BY
HOUSE.SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.OB �O EXCEPTION R DED
WORK TO HOUSE SEWER ' 1.00
ALTER OR REPAIR EXISTING N0. I DATE 8Y
SEWER OR DISPOSAL SYSTEM 1.00
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1.00 CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/ORDRAINFIELD 2.00 STATION DEPTHj
CESSPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 2.00 �`p+/ d MANHOLE'REFERENCE
q� LOWER
X33 t))
TYPE OF CONNE�TI LENGTH FROM
OWNERS PERMIT 00 Y. CURB P.L. M.L.'TO P.L.
AUTHORIZATION TOTAL FEE
1 HAVE THIS DATE.CONTRACTED WITH THE HER IN NAMED
CONTRACTOR TO CONNECT THE ABOVE-DESCRIBED EXISTING APPROVALS INSP.ECTOWSSIGNATURE DATE
DWELLING TO THE��P..U�BBLIC SEWER
SICMED THIS_mma v_u-DAY OR.. _ ____19:x_ NEW HOUSE SEWER Jf/J0� /Q-•�'/�
OWNER OR I�J 00 NECTADOITIONAL ]�
OWNERS EN �C7fd' BUILDING OR WORK
_..__1 ._.._. ,__ .._
EPTIC TANKSE
ADDRESS...__.__ ._ AND/OR DRAINF ELD PIT(S)
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLI• CESSPOOL. DRYWELL
CATIONAND STATE THAT THE ABOVE 18 CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER,REPAIR.SEWER OR
HEQULATING PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED DISCONNECT PLUG AND
AND/OR LICENSED AS REQUIRED BY LOS ANGELES .COUNTY• ANDON HOUSE SEWER
AND STATE OF CALIFORNIA OR THAT 1 AM LEGAL OWN- _
ER OF THE ABOVE IBE IDEN PROPE A'CKFILL SEPTIC TANKS❑
SIGNATURE SEEP.PIT(S)[] CESSPOOLS `fL
OF PERMITTE _�.
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