HomeMy Public PortalAbout6441 TEMPLE CITY BLVD_Sewer__ I
�°�•°•AS N 602 It SO APPLICATION FOR PERMIT 1
DIVISION OF BUILDING AND SAFETY 'SEWER—SEWAGE D I SPOSA L
Devil of Co" Engineer
County of TAG Angeles BUILDING / c C
JOHN A LAMBIE COUNTY ENGINEER ADDRESS tip T K.
m CASSATTD GRIFFIN SurTGr B011_nINO LOCALITY T! 1
FOR APPLICANT TO FILL IN CROSS
SSSr 0 T1
DESCRIPTION LOT No S. e o F C I- 2f I O OWNER �j Q
BLOCK TRACT %a. �R N~rr ND ADDRESS
SIZE OF LOT 5L 1[ J O NOWNO OON LOTS CITY TEL NO
USE OFILDIN 65 DISTRICT NO GROUP YAP
po
CONTRACTOR MOM'FREY PARK PLUMBING CO. 10YK
ADDRESS
410 SO GARFIELD AT 2.2604 CONNECTION DATA
CITY PORK, N STATION OEPTX
�/ CA
MANHOLE REFERENCE _ UPPER
REGISTRATION NO I Q 6 �� G' '3� STATE LOWER
❑ COUNTY /
No DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO TYPE OF CONNE SOA LENGTH FROM
PUBLIC SEWER S S SO Y RB P L L TO P L
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD ® 13 00
OVERFLOW SEEPAGE PIT DRAINFIELD P C
EXTN CESSPOOL ORYWELL MANHOLE S 100 CO I JO !
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM ® S 1 00 TRUNK PERMIT NO ROAD PERMIT NO
CON N ECT ADDITIONAL BLDG OR Q STATE ENCROACH:
WORK TO HOUSE SEWER ® $1 00 PERMIT NO
ALTER REPAIR OR ABANDONHOUSE INDUSTRIALIt
SEWER OR DISPOSAL SYSTEM ® $
1 00 WASTE APPR AL
CHARGES
CONNECTION CHARGE FEE
OWNER'S Pmum S DD r/
AUTHORIZATION TOTAL FEE l REIMBURSEMENT FEE cJr
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- APPROVALS DATE INSPECTOR SSIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER NEW HOUSE SEWER 'L-
SIGNED THIS DAY OF ' 19_ CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK
OW NERB AGENT SEPTIC TANK,SEEP, PIT(S)
ADDRESS AHD/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION CESSPOOL❑ DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWEROR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AN PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON USE SEWER
CALIFORNIA OR THAT I AY THE LEGAL OWNR OF THE ABOVE
DESCRIBED RESIDENTIAL PROP TY BACKFILL SEPTIC TANKS
SIGNATURE ' SEEP PIT(S) ❑ITTCESSPOeO'LS❑ �A
OF PEKYEE /•
( o Qlo of/L I
JOHN A LAMBIE Cou ENGINEER /' V�Aj�ATION ROBERT A WOOD,CHIEF PLeSP
G INECTOR
1/CvX J" —Y O CASH
2S; Kc24 1 0 A 300 M