HomeMy Public PortalAbout6133 TEMPLE CITY BLVD_Sewer__ .EEIDe APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES
SEWER—SEWAGE DISPOSAL.
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A. LAMBIE, County Engineer AUDRE
WILLIAM A. JE:NSEN, Sup'# of Building
orAL r _ r --- •. _— .___ ---
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FOR APPLICANT TO FILL -
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ADDRESS . CONNECTION DATA
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OL.:,E SEWER CON IEC TNG TO .---_.- ,.._--._-._. 0'RRUNK PERMIT NO. ROAD PERMIT^1.0
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ALTER.REPAIR OR ABA NOD&HOUSE— _-_ _ HWY.OR ST.WIDENING
' SEWER OR t]!SPGS,$L-SYSTEM $3.00 ______._- STATE EN-C.ROACHMENT
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CHARGES
OWNER' PERMIT f –_-•_—_
CONNECTION CHARGE.FEE
AUTHORIZATION TOTAL FEE _ --- ---- ------ ------- -- - -
HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON. REIMBURSEMENT-FEE ..
TRACTOR TO CO,NNFCT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE F'U BL IC .SFWE.R.. APPROVALS I 'LATE i INSPEC-ro 5 SiGNATURE
SIGNED 'THIS
OWNER OR r NEW HOUSE SEWER. -
__.--_-
i
O:'NNF HS AGENT______.__—_,__--__._______ ____ _ CONNECT ADDITIONAL
ADDRES.c BUILDING OR WORK 1 �-----
SEPTIC SEEP,PIT(Si 1
7 ItiERE BY' ACKNOWLEDGE THAT I HAVE READ T'r1E5 APPLICATION AND i:JR DRAT DRAT NPl E.LD � I
AICD STATE THAT THE .ABOVE !S CORRECT AND AGREE TO COMPLY
WITH ALL -COUNTY ORDINANCES AND STATE LAWS REGULATING
P_U?IU!NG AND 3EWERS. CESSPOOL [ I GRYWELL ❑ -yII f
--_
r
HrRERY t7FFT! Y THAT t AM PROPERLY REGISTERED AND/OR ALTER REPAIR,SEW R OR _--�I--f - -
t !'E LASED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF S WAGE DISPOSAL SYSTEM
t_A LfFOR.N!A OR THAT I AM THE LEGAL OWNER OF, AND INTEND 70
DiSCONNFCT PLUG AND
RESIDE
V' , 7tiF ABOVE DES(41BERD:NT AL PHsO4 ERf"'Y8. ABANDON
HOUSE
SIGNATURE
D PEPMITTACKFIsEC SSr 0CssOOL$
----- - - -
TANK [j �-----------
VALIDATION ROBERT A. WOOD
CK. M.0. GASH
SUPERVISING MECHANICAL ENGINEER
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6A642J-62 D APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION SUILDING "'L,
JOHN A. LAMBIZ County Engineer FADO RESS 4
WILLIAM A. JENSEN, Sup't of Building
L o_A
OCALITY
FOR APPLICANT TO FILL IN C SS ST.
DF 5 c k I PT ION SOI
0 WN E R
MAIL
BLOCK T ADDRESS
NO
SI-12 DF LOT NI�W ON LOT CITY TEL, NO.
13SE OF
BU
ILD;NQS DISTRICT NO. GROUP MA ��3 BYEIK P PG PROCES
'
CONTRACTOR
ADDRESS CONNECTION DATA
44
C TY 'TEL, NO,,._ ST I ON DEPTH
4-1-
REGISTRATION NO. MANHOLE 7-
C 0 u'41 Y
WORK FEE ?F C WL GTN FROM
No, DESCRIP_!ON 0 ZL.-. Z-
HOUSE SEWER TO- y WL.TO P.L ers
PUBLIC SEWER "'P 35.00
--I--- ---- --- P.C'NO.
SEP-,1C TAN K,_SEEPAGE PIT OR CO.IMP.NO. JOB NO.
PITS AND/O-RQRA!PFIEL $1000
HOUSE SEWER CONNEC71NG TO
TRUNK PERMIT NO. ROAD PERMIT N
PRIVATE DISPOSAL SYSTEM @ 53-o0
-NO DATE
WORK 70 HOUSE-Sr WER S3,00OVERFLOW SFE:PAC-L PIT DRAINFIELL
EXTN-CFSSPOOLDRYWELD L, MANHOLE:a s5.0o
kfTE.R'-REPAIR ORABA NOON HOUSE --------- H'WY.OR ST.WIDENING
OR DISPOSAL SYSTEM @ $3.00
STATE IENCROACHMENT
T PERM
INDUStI41AJ
CHARGES
MIT 5 21 00
OWNEWS
CONNECTION CHARGE FEE
AUTHORIZATION I_mT-A-L-F-E- E -7
IHAVE AT THIS DATE A CONTRACT WITH THE HEREIN",NAMED CON, REiMEURSEMENT FEE
r RACTORTO CONNECT THE ABOVE DESCRIBED CX,STING DWELLING
P'"a I_1C SEWER. APP
TO THE ROVALS DATE i INSPECTOR'S SIGNATURE
SIGNED THIS----DAY OF'------19--
OWNER OR NEW HOUSE SEWER
OWNERS AGENT—------------------- CONNECT ADDITIONAL
EaL;IL DING'DR WORK
SEPTIC TANK.SEM PIT(S)
,, ,
IHE-.F?ESY ACKNOWLEDGE THAT i HAVE READ THIS APPLICATION AND/OR DRAtNFIFLO
STA`E THAT THE ABOVE IS CORRECT ANO AGREE To COMPLY
.__—
WITH AIL COUNTY ORDINANCES AND STATE LAWS RtGULATIMG
PLUM. WNG AND SEWFRS, CESSPOOL LJ EltiYWELL
------ -------
I HEREBY CERrIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER,REPAIR,SEWEF?OR
EN,'ED AS RCQjIREO Sv LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
-ORN A C. L-GAL OWNE '-"�OF' AND INTEND TO 6)s-C-0-N-N--F,-C-T-P'-LU"GAN-D
CA'A� I R THAT 1 4,M THE E
14 F�SIDE IN, THE J..SIL)EF"L P R0,PERTY.
ABANDON HOUSE SEWER
SIGNAT UREPf
BACKFILL SEPTIC TANKS
OF 5FEP,PIT(S) Q CESSPOOLS
-------VALIDATION ROBERT A. WOOD
CK. W 0. CASH SUPERVISING MECHANICAL ENGINEER
143 AUG
2 6 1 0 0 7.0 0-
LAW 3 5
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