HomeMy Public PortalAbout6131 TEMPLE CITY BLVD_Sewer__ ,E80D 10-02
'S.A 84:1pAPPLICATION FOR PERMIT ,��;V,31 -j
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
,012.N A, LAMBIE, County Engineer ADD RE!n
WILLIAM A. jENSEN, Sup" of Building LOCALITY
NEAREST
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FOR APCRI
APPLICANT TO FILL IN ---ES---
DEscH FT ON T OWNER
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ONTRACTOR
ADDRESS CONNECTION DATA
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NO. DESCRIPTION OF WOR
FEE TYPE OF CONN.FCTION LE-kCTH FROM 0
HOUSE SEWER CONNECTING TO Y, M.L.TO P.L. 0 9d
PUB LIC-51EWER @ $--:.Do � 1 4-1
T SEP 4:7ANJ -SEEPA�-GtPIT'-64 -'--@- Ac
PITS AND/O�DRAINFIELD Co.IMP. NO.
JOB NO
1 5--E-W-ER—C OJN-N E C-Th—NG-T-0
U TRUNK PERMIT NO. ROAD PERMIT N, 6,,,-,
PRIVATE DISPOSAL STEM @ $3.00
CTNN HEADDITIONAt_BLDG64--
WIVRR I EAFEMENT RECORDINSTR.NO. i DATE
WORK TO HOUSE SEWER $3,00
FXTN.,Cr-SSPO')!.,r)RYWELL-MAf4HOL.E @ $5,00
HWY.OR ST-�;�IDE NiNG
SEWEJR OR DISPOSAL S)�STEM S3 GO STATE Emtf OACH MENT
PER?4�7
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11 OTAL
WASTE APPROVAL
CHARGES
OWNER'S PERMIT
CONNECTION CHARGE FEE
AUTHORIZATION I -TOTAL--rii
I HAVEAT THIS DATE A CONTRACT WITH THE HERFiN NAMED CON- REIMBURSEMENT FEE
TRACTOR CONNECT THE ABOVE DIESCRIBEC EXISTING DWiY.LLiN`.:;
TO ON IEWFR� APPROV
FL,
TO THE 5"�!C EALS .>_____DA1 E ' NSP EC S TOR' SIGNATURE
SIGNED THIS DAY OF-,.-------------I9--
OWNER
ER OR NEW HOUSE SEWER
OWNERS AGENT---------------------__ CONNEC rADDITIONAL
8UILDIN G OR WOR K
SEPTI1 TANK,SEEP,PIT(5)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
Amo/orq r>RAINFIELD
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING II
PLUMBING AND SEWERS. CESSPOOL Cl. DRYWELL El
IHEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND'OR ALTER,REPAIR.SEWER OR
LICENSED AS REQUIRED BV LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF. AND I NTEND TO D175CONNECT PLUG AND
R E51DE IN, T]F*E--A,9O1,'E DESCRIBED RESIDENTI�,4 PROPERTY' ABANDON HOUSE SEWER
SIGNATURE
Or PERMIT
BACKFILL
LS) r Ii:TANKS
SEE?.PIT S) CESSPOOLS []I
VALIDATION ROBERT A. WOOD
SUPERVISING MECHANICAL ENGINEER
O. CASH
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16A64 2D APPLICATION FOR PERMIT
t;
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION Bit DRESSLDING � y�
10HN A„ LAMBTE, County EngineerxV �
WILLIAM A. JE?JSEN, Sup'4 of Building
LOCALITY v M• -d,-..i=L _ _.,A- ,-g-. ___ _�
NE RE f 1
FOR APPLICANT TO FILL IN GROSS ST
DcSCR 1 ON LOT NO 'f
.. _...- IEEE. .#.. .:b OWNER ,Y-•t'A'�'-_- -�"" SG
Y.
MAIL
BL,C}CK. TRAt..T is '', l 3 F,DDRESS_-_____-.___.___.____-.-_ _.____...._._-.,
NO. OF SLOGS-
SI/E: OF_LGT hItOW ON LOT CITY TCL. NO.IEEE-
_-
USE OF
sun DINGS DISTRICT NO. GROUP MAP PROCES$E;D BY
f3Fl PG
CONTRACTOR
ADDRESS f _ �' S ,,-.t CONNECTION DATA
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,€ :'. /' ST.°Td I7 DEPTH yf;.
u'1 i_ ' R L NOS 9 - _-. ! -- _-
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> ��_
REGISTRATION N(? --�'-'- --- M. Pv.i Of E R'FcREN
_ 000 -6/` El c.OU NTY .r -a'KrE`�%.
NO J SCRIPTIQN FRK Fr/ OF-' LENGTHFP.OM _� _
_
! HOUSE SEWER C.ONN.ECTING 3'O � � y'' r/ GURF P.C.. M.L TO P.L. l
J i.F4 Bt,C SE'IV E'R @ $5.00 _ , NO,
---- ---- -- -- +-= /
-. ___ PTI'TANK,SEEPAGEP'I'T OR NO-
JOB >
PITS AND/175R DRAINFIELD 'rte` $10.00 .IMP P•f0
Y _
HOUSE SEWER CONNECTING TO �� TRUNK PERMIT NO ROAD PERMIT
.._ F_DISPOSAL SY 53EM ..___� $3.'00
_�PRIVAT
C ONh-C ADDITIONAL SLOG OR j AFFIDAVIT I WAIVE ERS EMENt RECO RU.INSTR NO.r DATE
_..-:I WORK 0 HOUSE SWrR @ $3,00
CVERF OW S£.EPA E PIT,DRAINF ELD $5.470
L
EXTN. E SPOO.L..DRYWELL,MANHOL;E(�
__-_.-. __r_- -__ _D- __.___ _. ___.:_-___...; HWY,OR ST'.WIDENING
1 A TER,RcPAtR Oft ABANDON HOUSE
SEWER'OR DISPOSAL SYSTEM3.00
STATE:FNPROACHMENT
I PFRMiT IO
INDUST AL
CHARGES
OWNER'S PERMIT
.-----
- — $' !–.
21 00.-- _ CONNECTION
-—CHARGE_.F.-�'E-EAUTHORIZATION TOTAL FEE �----_—.—._.. —.__.-- -----..
-
'1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TR
ON- RtIMBi1RSEM EPd7 FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING —_.__._._— __ -- ._._._.TETE _'�-
TO THE PUBLiC SEWER. APPROVALS DATE I INSPECTOR'S SIGNATURE
SIGNED THIS..__...—_DAY
OWNER Oft NEW HOUSE SEWER
OWNERS
---
t_ -N w A.C: N.,_.__-._ CONNE 'r ADDITIONAL I I
ADDRESC_-. �.. tlU[LDfYG OR WORK
IPTIC TANK..SEE PITS)
I HF4FRY ACKNOWLEDGE -r';AT 1 HAVE HEAD THIS APPI-.1_ATION AND/OR D.AINriELD
AND -TATE THATTNF. ABOVE ISI CORRECT AND AGREE "TO COMPLY
W IT'H ALL CDC UNTY ORDINANCES AND STATE LAWS REGULATING
P i,UM
SING AND SEWERS CESSPOOL ❑ DRYWE.LL
.
I HEREBY CERTIFY 7 HAT AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,.SEWER OR i
I._1:CENSED AS REOUIRF.C, BY lLOS. ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIt`EJR±N, OR THAT I AM THE LEGAL OWNER OF, OP INTEND TO DISCONNECT PLUG AND
ASAND
� � e .r. _-- 5EEF>>,A!'Ty(B) �r`SF CESSPOOLS
RPSiO IN, THE AUE DFSC RI Rt Sf liF`N"!IA! PROPERTY.
_
Sls�hfATC}RE _y.- f -�
OT' PE RM:TTE E, +_ BA"KFILL SEPTIC TANKS ❑ -I ---
A IDATION ROBERT A. WOOD
SUP.EfRVISING MECHANICAL ENGINEER
;''CK. M.O. CASH -