HomeMy Public PortalAbout6404 TEMPLE CITY BLVD_Sewer__ &9 Aef 11 BB APPLICATION FOR PERMIT 1
DIVISION OF MUD= AND SAFETY SEWER—SEWAGE DISPOSAL
D"artmem of County Engineer
COUnly Of
LOS Angel" euILDIRG
JOHN A LAMBIE COUNTY ENGINEER ADDRESS
® CASSATTO GRIFFIN SUPTOFBUILDINU LOCALITY
F A AP?( / CROSS ar
LEGAL .. �J OWNER
DESCRIPTION L T NO J
MAIL
BLOCK TRACT 7 ADDRESS
,X NO OF SLOGS
S12E 0 j NOW ON LOT CITY NO
USE OF
BUILDIM64 DISTRICT NO GROUP YAP
BK PG
CONTRACTOR _ .+ Z
CONNEC= DASA
ADDRESS
STATION DEPTH
TEL NO
MANHOLE REFERENCE
❑ STATE LOWER
REGIATIOX NO ❑ COUNTY
ND DESCRIPTION OF W09k FEE
HOUSESEWER CONNECTING TO TYPE OF CONNECTION LENGTH FRON /
PUBLIC SEWER @ $B BO CURB P L Al L TOP L
SEPTIC TANK SEEPAGE PIT OR
PITS AND/OR DRAINFIELD ® $3 00
OVERFLOW SEEPAGE PIT DRAINFIELD P C NO
EKTN CESSPOOL DRYWELL,MANHOLE $2 00 CO IVP NO JOB RO
HOUSE SEWER CONNECTING TO /0� 90
PRIVATE DISPOSAL SYSTEM ® $1 00 TRUNK PERMIT NO ROAD PERMIT NO
CONNECT ADDITIONAL BLDG OR STATE ENCROACHMENT
WORK TO HOUSE SEWER ® S 1 00 PERMIT NO
ALTER REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM Sim WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNER'S PERMIT S 1 00
AUTHOREZATION TOTAL FEE REIMBURSEMENT FEE IPA _7
1 HAVE AT THIS DATE A CONTRACT WITH THE HER IN NAMED CON- APPROVALS DATE INSPECTO SSIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER NEW HOUSE SEWER L (f
SIGNED THIS DAY QF 19_ CONNECT ADDITIONAL
OWNER ORVo BUILDING OR WORK
OWNERS AGEII] SEPTICTANK SEEP,PIT(S)
ADDRESS AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT HAVE READT S APPLICATION CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND A REE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR AM THE LEGAL 0 ER OF THE ABOVE
DESCRIBED RES IA PROPERTY BACKFILL SEPTIC TANKS
SIGNATURE SEEP PIT(S) [I -2
OF PERMITTE
JOHN A L.AMBIE COUNTY ENGINEER VALIDATION ROBERT A WOOD CHIEF PLBG INCPECTOR
CK ■ 0 uKx
LACp3 5 3 3n OEC 19 4 5-50 o