HomeMy Public PortalAbout6106-6108-6110-6106 1/2 TEMPLE CITY BLVD_Sewer__ 76A663 12-84
EfifiAPPLICATION FOR PERMIT
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DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Department of County Engineer �r
County of Los Angeles BUILDING Y x J
WIVI.J. FOX, COUNTY ENGINEER _ADCRE5� � . .L' _.',
CASSATT D. GRIFFIN, SUPT OF BUILDING LOCALITY
FOR APPLICANT TO FILL IN NEAREST
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LEGAL e. ----•_— ,+.�, 9; w _
DESCRIPTION LOT NO. +
. OWNER
.BLOCK TRACT MAILa-
f —/C ADDRESS f
BLDGS.
SITE OF LOTf h NOW ON LOT j CITY TEL. NO.-
USE OF ---- + --r'
BUILDCNG5 + = .,�,z IL _ _ --
s DISTRICT N+ . GROUP APAP
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CONTRACTORIf -ay E - -- f ( m ' •_r+ -
ADDRESS ! ; CONNECTION DATA
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CITYltw i .,dLx. TEL. NO. AtZ 2`61 q__ STATION ,e .�,. � ;. DEPTH S Y
❑ STATE. MANHOLE RETERENCEY -.-
REGISTRATION NO. - i_r COUNTY _ 6J , /J.c _ �LOWE
-- "-"- TYPE : NECTION L.ENGrH FROM - -"FEE -
No. i DESCRIPTION Or WORKWORKcURB� -ate., A.L. TO P.L.
s---- ---
HOUSE SEWER CONNECTING TO. I'
PUBLIC SEWER zr_$ 3.50_ -
HOUSE SEWER CONNECTING'i0 I`
PRIVATE DISPOSAL SYSTEM_ 1.04 1 - -
CONNECT ADD[Tl'O'JkL BLDG. OR `1+ CO. IMP. NO f - JOB. NO.
WORK TO HOUSE SEWER
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ALT R OR REPAIR EXISTING
SEW CRDISPOSAL S STEM T 04 TRUNK PERMIT NO. - ROAD PERMIT NO
D s ONNE T AND ABANDON SEWER STP TE ENCPERMIT
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_I AND/ORDISPOSAL SYSTEM_ _ _4.00 + I_ `_ PERM;T N_
tv ;C TANK SEEPAGE PIT OR.
P TS AND/CR " ,A NFIELD2 00 i ( `INDUSTRIAL
-- ___
WASTE APPROVAL
CESSPOOL URYWL L - )
SPECIAL CONDITIONSONLY F 00 I
.. ...__—._ CHARCES
..CONNEC'T'ION CHARGE FEE
OWNER'S PERMIT
AUTHORIZATION TOTAL FEE j REIMBURSEMENT FEE
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING UWLLL+NG APPROVALS DATE INSPECTOR'S SI NATURE
70 THE PUBLIC SEWERNEW HOUSE SEWER
SIGNED THIS `DAY OE_la:cv ---
OWNER OR CONNECT ADDITIONAL
' BUILDING OR WORK
OWNERS A G E jl TS -�'�4 ,[�• 'rG�, t�'�, — _—.--�--- -
--SEPTIC TANK, SEEP PIT(S)
D
_A N D;O R D R A I ti P I£'_D
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION CESSPOOL DRY'NELL
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 REGISTERED AND/OR
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND 4
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE ABOVE ABANDON HOUSE SEWER
DESCRIBED RESIDENTIAL PROPERLY. BACKFILL SEPTIC TANKS 0
-�
SEEP [J
a" .PIT(S)J3 CESSPOOLS I-! -
SIGNATURE
OF PERMITTEE - '
WILLIAM J. FOX, COUNTY ENGINEER VALIDATION
in
27
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BY
DEPUTY DEPUTY
BY BY
u DEPUTY DEPUTY �`