HomeMy Public PortalAbout6114 TEMPLE CITY BLVD_Sewer__ 7SA6420
E663 ii-55 APPLICATION FOR PERMIT 1
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DIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
Department of County Engineer _
County of Loa Angeles Bu1tDINc /'
JOHN A. LAMBIE, COUNTY ENGINEER=�j
ADDRESS �r�ud
CASSATT D. GRIFFIN, SUPT OF BUILDINGSr..
LOCALITY
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_ FOR APPLICANT TO FILL IN doss s_T.
LEGAL A c
.DESCRIPTION LOT NO. OWNERn..
MAIL
BLOCK TRACT
NO. OF BtDGS°
SITE OFLOT NOW ON LOT CITYTEL. NO, -
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USE.OF -- j'', . ,�,,, DISTRICT N0. GROUP MRP
SUIL_DiNGS .'7 �"_..k "` :"� BK PG
CONTRACTOR�y111tq; �' _'. -Lr$t s..• 1 y --1 ""' '�,_
s<d — --
ADDRESS '�.Y CONNECTION DATA-
.—. .�.`-,/ -- / --
. -STATIONDEPTH
CITY j TEL. NO.. � --• - --t--=—
-----' --------"-.- --_�� MANHOLE REFERI NCE •UPPER ),
STATE -}- LOWER_
REGISTRATION N0. �.v ,.� inCOUNTY ---- } T
--- � -
N 1 0. 1 DESCRIMON OF WORK FE ---
L -- _--.. --- _-- -.— - TYPE OF CONNECTION .__.. _LENGTH FROM -.—
HOUSE SEWED CONNECTING TO ". Y. CURB / P.L. M.L.TO P,L,
j_�'JBLIC EWER cm 3.50 ., � __------ ��--
SEPTIC TANK SEEPAGE PIT OR --�_ -� -- ^---
_--__ PITS AND,
OR DRA1NFI LD _ (t $3,00
}OVERFLOW SEEPAGE SEEPA F PIT, DRAINFIELD � .-� .., P. G. N0.
1 EXTN.,CESS:"7UL,PRYWELL,MANNOLF C(G $2.001 CO. IMP, NO. JOB NO.
NOUsE StWER CONNECTING TU �� d
_� PRIV-ATE DI POSAL SYSTEM _ ._-- 0 $1.00 ^ TRUNK PERMIT NO. ROAD PERMIT NO, + I-t" ���?
CONNECT ADDITIONAL BLDG.OR I - STATE ENCROACHMENT'
WORK TO HOUSE SEWER _ _-.--Ci4 $1.0.0 -_--i --__- _PERMIT NO.
ALTER,REPAIR OR l BANDON HOUSE I INDUSTRIAL-- --_--- —`--�—_--
SEWER OR DISPOSAL SYSTEM r $10 1)
WASTE APPROVAL
'----`-- .I CHARGES
CONNECTION CHARGE FEE -- --- _---
OWNER'S PERMIT — --- -_-- - —.— _— - ---- - -------
7...- REIMBURSEMENT FEE
AUTHORIZATION TOTAL FEE
[ HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAPPROVALS DATE ,NSPECTOR'SSIGNATUREAMED CON-
TRACTOR 'rO CONNECT THE ABOVE DESCRIBED E;STING DWELLING
TO THE PUBLIC SEWER. NEW HOUSE SEWER
SIGNED THISDAY OF 19 -- CONNECT ADDITIONAL ----
OWN UR s y' ? .A .,� .,r Y, L1ILDING,OR WORN
OWNERS OR
OW __--
- SEPTIC TANK,SEEP,PITS) j I
AND/OR DRAINFIELD--- --
I HEREBY ACK'J 0'A+tEDCE THAT I H.AV READ THIS APPLICATION CESSPUUt i] DRYW ELL❑
AND STATE THAT THE A606'E !S CORRECT AND AGREE TO COMPLY _
WITH. ALL COUNTY ORDINANCES AND STATE LAA'S REGULATING ALTER,REPAIR,SERER OR
PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
-- -- ---
I
I HEREBY A CERT:FY THAT i AM PROPERLY REGI FRED AND/OR DISCO-NECT PLUG AND
LICENSED AS REQUIRED BY LOS A-NGELES COU AND STATE OF
CALIFORNIA OR THAT f ABANDON HOUSE SEWER
}!"f�M Y,iE LEGAis O,' Eft OF THE .ABOVE --. ..._ -- - ----- ---
DESCRIBED RESIDEN/� PROPERTY, ,,r^' BACKFILL SEPTIC TANKS I1
SIGNATURE `0"' �- - SEEP .P1T(S. CESSPOOLS;]--- -... ------. ---
OF PERMITT. - .yT�f' ...C( -G '"�.. '
JOHN A. LAiMHIE, CQ,6NTY ENGINEER r-y, ALIDATION:_., R.OBER-r A. WOOD, C.IEF PLBG. INSPECTOR
0. `CASH
4, .0 7 3 4 AM 28 4 A . 50 �.
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