HomeMy Public PortalAbout6221 TEMPLE CITY BLVD_Sewer__ DEPA1lLflIEWT OF COUNTY ENGENEES SEINER-SEWAGE DISPOSAL
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELES
WILLIAM J. FOX, COUNTY ENGINEER I AUILDING
DDRESS
FOR APPLICANT TO FILL IN LOCALITY
BUILDING q � ] f
ADDRESS ' ■ �"� II fi'"°—TC
ST. O ll q
LOCALITY ��� DISTRICT NO. �j SERIAL
/NO. -PERMIT NO.
CROSS ST Grit L! 4.rti�r _ �^ ` /G lO 10-40
`S
! �y RECEIVE Y Ready for Inspection DATEISSUED
OWNER // t /�/� fiir aY� ry, �! �� v 3
ADDRESS !o�� 9 �1 , ��P ✓ r S�,t' ?�,SE ZONE OCCUPANCY MAP
I
CIT Yr d f�C ���irREL.NO. BK PO
CONTRACTOR A,l•i" 'L;e„ • ex"'1r�_,•�-'` �.
J' CO.IMP.NO. 1� �
� - 34
ADDRESS�Q ��3 .. r✓`��• JOB H0. !
CITY �wU/�Q TEL.NO 6 7 TRUNK PERMIT NOJ
STATE S /
REGISTRATIO 1 N0. 29 EGAL 56 ((��0,tff ® COUNTY ROAD PERMIT NO. t
DESCRIPTION PTION LOT NO. Jy'� ! S �D STATE.ENCROACHMENT
PERMIT NO. 1 %
BLOCK M yTTRACT � ,� � 7/+ ,INDUSTRIAL
o WASTE APPROVAL.
312E OF LOT u� OF
X NOW ON LOTS v- - CHARGES
USE OF
BUILDINGS '[ CG6C'-4`C.Aw CONNECTION CHARGE FEE
NO. DESCRIPTION OF WORK FEE
--
HOUSE SEWER CONNECTING TO - REIMBURSEMENT-FEE
PUBLIC SEWER 0 $ 8.50 RECEIPT NO. DATE BY
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1.00
CONNECT ADDITIONAL BLDG.ORC}C+ EXCIyFTION RECORDED
WORK TO HOUSE SEWER 1:00
ALTERORREPAIR.EXISTING N�•,I' DATE I BY
SEWER OR DISPOSAL SYSTEM 1.00
DISCONNECT AND ABANDON SEWER
AND/OR DISPOSAL SYSTEM 1.00 "CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 2.00 STATION DEPTH
CESSP00 L—D RY W EL L
SPECIAL CONDITIONS ONLY 2.00 MANHOLE REFERENCE
i UPPER LOWER
TYPE&CONNECTION LENGTH FROM
OWNERS PERMIT ; _ 1 00. Y. CURB P.L. M.L.TO P.L.
f
AUTHORIZATION I TOTAL FEE 1 2-
.1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER.
SIGNED THIS___.._.-...DAY OF.._.____ _19- NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT_....._:..„...�_.._.._..._..._.---•..._.._......:._..............._ BUILDING OR WORK
SEPTIC TANK.SEEP.PIT(S)
ADDRESS.........._„.._......_..._._..___..._._.._..__._....._-----------------6........ AND/OR DRAINFIELD
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLI- CESSPOOL[] DRYWELL
CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE,
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER,.REPAIR,SEWER OR
REGULATING PLUMBING AND SEWERS. SEWAGE DISPOSAL SYSTEM
1. ,HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED. DISCONNECT PLUG AND
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOUSE SEWER
AND STATE OF CALIFORNIA OR THAT 1 AM THE LEGAL OWN-
ER OF THE ABOVE DESCRIB RESIDENTIAL PROPERTY. BACKFILL SEPTIC TANKS
SIGNATURE ,�� �►A„// SEEP.PIT(S)� CESSPOOLS
OF PERMITTEE.. .......__�..----...._._.. _.
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