HomeMy Public PortalAbout6113-6115 TEMPLE CITY BLVD_Sewer__ 76AB42D APPLICATION FOR PERM-IT 1
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DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Department of County Engineer
County of Los Angeles BUILDING•
JOHN A, LAMBIE, COUNTY ENGINEER -ADDRESS �� s ° rt
CASSATT D.GRIFFIN, SUPT OF BUILDING LOCALITY
NEAREST l 4
FOR APPLICANT TO FILL IN
LEGAL - I DESC'RIPTION LOT NO OWNER' AmijBLOCK TRACT {d.: MAILADDRESS
O OF BLDGS. -CITY TEL. N0.
_SITE OF LOT_ NOW ON LOT
USE OF -`- ---�- DISTRICT NO. GROUP MAP
BUILDINGS.
-�
K PG
_
CONTRACTOR s it 3' ," '-..
ADDx£5s _- CONNECTION DATA
l Y v J✓c' —---- --- ---- —
1 �r STATION DEPTH
CITY .:x_
MANHOLE REFERENCE
_-i� El- STATE �` LOWER
REGISTRATION NO, _ �"'y > .+'�� j• ,� [] COUNTY
N0. DESCP.fPTION OF WORK FEE
-
----I-- ---_---- ----- _ TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO �� Y. CURB P.L. M.L.TO P.L. _
PUBLIC SEWER @ _$_3.50 —-.. -------. ---
SEPTIC TANK,SEEPAGE PIT OR
_- @�_PiTS AND/OR DRAINFIELD �$3.GU _ _ -- -_.---.-_--. --- -_ .- ----
OVERFLOW SEEPAGE PIT,DRAINFIELD � P. C. N0,
EXTN.;CESSPOOL,DRYRELL,MANHOLE (n% $2.001 { CO. IMP. NO. JOB N0._ - --__
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM @ $1.00 TRUNK PERMIT NO. ROAD PERMIT NO.
�f CONNECT ADDITIONAL BLDG.OR i , ,,-> STATE ENCROACHMENT
�E I WORK TO
HOUSE
SE
�- WER �d °-s PERMIT NO..
- - -- '--- -- $1.00 E - ---
ALTER,REPA':R OR ABANDON HOUSE INDUSTRIAL
SEWER.OR DISPOSAL SYSTEM WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT $ t 00 REIMBURSEMENT FEE - --------- `--^--
-- - -
AUTHORIZATION 'TOTAL FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- APPROVALS DATE INSPECTOR`SSIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING �
TO THE PUBLIC SEWER. NEW HOUSE SEWER - -
SIGNED THIS DAY OF 19____ CONNECT ADDITIONAL
OWNER OR - BUILDING OR WORK
OWNERS AGENT ...
—,l/ SEPTIC TANK,BEEF,PIT(S)
ADDRESS ` Jt.�- AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL rJ
AN U STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
.WITH ALL COUNTY ORDINANCES AND .STATE LAWS REGULATING ALTER,REPAIR,SEWER OR i
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND T
LICENSED AS R,.;QUIRED BY LOS ANGELES COUNTY AND STATE OF p
DIBA SCONN HOUSE SEWER
CALIFORNIA OR THAT t F,ifi THE LEGAL 014NER OF THE ABOVE ----------------} ---__
AESCR.IBED RESIDENTIAL'Pj PERTY. ,+''/ BACKFILL SEPTIC TANKS El
SIGNATURE / � - SEEP.PIT(S)❑ CESSPOOLS
OF PERMITTEE. �C (J�: - ---
IS
OHN A. LAMBIE,Coupti-y ENGINEER VALIDATION ROBERT A.WOOD, CHIEF PLBG. INSPECTOR.
CIC. 41 O, CASH _