HomeMy Public PortalAbout6225 TEMPLE CITY BLVD_Sewer__ -
:��DB APPLICATION FOR PERMIT
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COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER tt� ENO,
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BUILDING AND SAFETY DIVISION BUILDING
ADDRESS ,Z )1JJOHN A. LAMBIE, COUNTY ENGINEER N oCOLEMAN W. JENKINS. SUPT. OF BUILDING LOCALITY l A4NEAREST
FOR APPLICANT TO FILL IN `"D5s ST. `"`� `L GAL LOT NO. OWNER .! i-C_. .DESCRIPTION MAIL
BLOCK TRACT �7ADDRESS
NOO BLDGS.SIZE OF LOT fJ' � NOW ON LOT - CITY
USE OF f DISTRICT NO. GROUP MAP
BU IIDINGS p' /L. `f -�- fie.: 0e. t' 1: K PG
_
CONTRACTOR - ! ll'a 6�'�C,+-tl9 �'!"4. If�Jee.:' __.��• ` _
ADDRESS CONNECTION DATA
STATION DEPTH
CITY L,)" C. TENO. VL; L..- / - UPPER
L
STATE LIC MANHOLE REFERENCE LOWER
LICENSE NO: ;� y (' CLASS 1.� V j,Nqo. --1,rD)ESCRIPTION OF WORK FEE TYPE OF CONNECTIONFROM
SE SEWER CONNECTING TOY_ CURB P.L. M.L.TO P.L.
LIC SEWER $5.00 P.G.NO.
TICTANK.S EPAGE PIT OR CO.IMP. NO, JOB NO.
AND/OR DRAINFIELD $10.00USE SEWER CONNECTING TO TRUNK PERMIT NO. RQAD PERMIT NO,
PRIVATE DISPOSAL SYSTEM W $3.00 _ d
_ __ _ --—
CONNECT ADDITIONAL BLDG,*R$- /,y,�t<) AFFIDAVIT WAIYlt EASLY ENT RECORD.iNbTR.NO. DATE C.J
TO HOUSE SEWER @ $3.00
OVERFLOW SEEPAGE ;;IT.DRAINFIELD ----------+----�- --- Q
j E%TN„CESSPOO CESSPOOL.
RWELL.MAN HOLE $5.00
~
_ _ --- HWY OR ST WIDENING
DU
ALTER.REPAIR OR ABANON HOUSE _
SEWER OR DISPOSAL SYSTEM __ 0_ $3.00 E
_-, .-j� STATE NCROACHMENT CL
If. PERMIT NOS �
-♦---- INDUSTRIAL
--� I WASTE.APPRC VAL --
__ IT __�-----�-_--_ CHARGES _ --
OWNER7S PERM $I zi oD --._--�
-�- CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE � ` -----_ —_.
REIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON
S ----- —_�
TRACTOR TO-CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER. _ -_ — --------
SIGNED THIS�. `._.DAY OF—l-
6,
F l
OWNER OR NEW HOUSE SEWER
OWNERS AGENT "�J -' L' frf L` CONNECT ADDITIONAL
BUILDING OR WORK
ADDRESS- i' E,r,LG t,'I.f"_ JY:
_ SEPTIC TANK,SEEP,PIT(S)
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY ------------
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING CESSPOOL ❑ DRYWELL Cl
PLUMBING AND SEWERS- __ -- ------ --'
1 HEREBY CERTIFY THAT i AM PROPERLY REGISTERED AND/OR ALTER,REPAIR.SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF, AND INTEND TO DISCONNECT PLUG AND
RESIDE IN. THE ABOVE DESCRIBED _U.SIDENTIAL PROPERTY. ABANDON HOUSE SEWER —
SiGNATUREBACKFILL SEPTIC TANKS E:ITTEE
OF PERM . SEEP,PIT(S) ❑ CESSPOOLS ❑
VALIDATION JACK R. ALLEN
SUPERVISING MECHANICAL ENGINEER
CK. � M.O. CASH
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