HomeMy Public PortalAbout6102-6104 TEMPLE CITY BLVD_Sewer__ DEPARTNOM of COUNTY ENS SEWER—SEWAGE DISPOSAL 1
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY or LOS ANGELES• Q
WILLIAM J. FOX, COUNTY ENGINEER AD RES$ X ! GCr
l 1 da; FOR APPLICANT T FI N LOCALITY
NEAREST
ADDRESS '^ CROSS ST.
LOCALITY DISTRICT NO. Ready for Inspection PERMIT NO.
NEAREST l I S
CROSS ST. C LVED BY DATE ISSUED BY DATE
a
OWNE Al A, / 5-27
MAIL
ADORE USE ZONE OCCUPANCY BK�MA PG
SS
CITU ��TEL.NO. f
CONTRACTOR
- CO.IMP.N0.
ADDRES�o JOB.N0. '
TRUNK PERMIT NO.
REGISTRATION N0. � ®COUNTY
ROAD PERMIT N0: � �k.7 0�,
LEGAL y� ,STATE ENCROACHMENT
DESCRIPTION LOT N0. v7 PERMIT NO.
BLOCK TRACT P 7 7 WASTE APPROVAL
SIZE OF LOT 0� �/ NO.OF BLDG&
NOW ON LOT � CHARGES
BUILDINGS_ ;'.' �yy -�i CONNECTION CNAItGE FEE
NO. DESCRIPTION OF WORK FEE REIMBURSEMENT FEE
HOUSE SEWER CONNECTING TO
PUBLIC SEWER ! : 8.50 RECEIPT NO. I ATE I BY
HOUSE SEWER CONNECTING TO
_ PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.OR EXC TIO RECORDED
WORK TO HOUSE SEWER 1.00 N0J� D TE I BY
ALTER OR REPAIR EXISTING. . 111
_SEWER OR DISPOSAL SYSTEM 1.00
DISCONNECT AND ABANDON SEWER
_ AND/OR DISPOSAL SYSTEM 1.00 CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR d
PITS AND/OR GRAINFIELD 2.00 STATION �/� a DEPTH
CESSP00 L—D RY W ELL
SPECIAL CONDITIONS ONLY 2.00. g 9 MANHOLE REFERENCE
3 VPPER-- LOWER
TYPE OF CONNECTION LENGTH FROM D
OWNERS PERMIT $ I CO. ,, CURB -PoL. M.L:TO P.L. Q.6 •--
AUTHORIZATION TOTAL FEE _ - O
I HAVE THIS DATE.CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER rr _
SIGNED THIS_ DAY OFNEW HOUSE SEWER
CONNECT ADDITIONAL
OWNER OR. BUILDING OR WORK
OWNERS A N .,F.'
ADDRESS dC_ ..:`_ AND/OR DREPTIC AINF ELSEEP.D PIT(S)
I MEREB CKNOWLEDGE THAT 1 NAPE READ THIS APPLI= CESSPOOL 0 DRYWELL
CATION AND STATE THAT THE ABOVE IS 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.
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY, DISCONNECT PLUG AND
AND STATE OF CALIFORNIA OR THAT 1 AM THE LEGAL OWN- ABANDON HOUSE SEWER
ER OF THE ABOVE CRIBED EN TI L PROPERTY. BACKFILL SEPTIC TANKS
SIGNATURE ,,/ SEEP.PIT(S) CESSPOOLSD
OF PERMITTE _.
TOA642D S&E 663 4/54 ���� A-V r`yll. '41161