HomeMy Public PortalAbout6446 TEMPLE CITY BLVD_Sewer__ 5
aaK6 APPLICATION%FOR PERMIT 1
BDIVISION OF BUILDING AND SAFETY SEWER-SEWAGE DISPOSAL
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BUILDING
WM.J. FOX, COUNTY ENGINYfR DORE59 1 I
CAYYATT D GRIFFIN.YUP T OF BUILDING LOCALITY
FOR APPLICANT TO FILL IN ReREADRss"sk MDYV
DESCRIPTION LOT NO / LG OWNER
BLOCK TRACT MAIL
ADDRESS
-3,111
NO OF BLDG! yl�
USE OF CRY OF LOT NOW
ON LOT alaid TEL NO
USE
BUILDINGS ' DISTRICT NO GROUP YAP
CONTRACTOR BK P6
O E 2
ADDRESS ` CONNECTION DATA
CITY( TEL NO G S a STATIORJ z-t DEPTH
❑ !TATE / MANHOLE REFERENCE
REGISTRATION NO / 3 3 ❑ COUNTY •,7Z''� #L LOWER
TYPE OF CONNECTION LENGTH FROM
NO DESCRIPTION OF WORK FEE Y CURB PL Y L TO P L
HOUSE SEWER CONNECTING TO
PUBLIC SEWER ® f 330 _
HOUSE!EWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 100 _
CONNECT ADDITIONAL BLDG OR CO IVP NO JOB NO
WORK TO HOUSE SEWER 100
(ALTER OR REPAIR EXISTING '
SEWER OR DISPOSAL SYSTEM 1 00 TRUNK PERMIT NO ROAD PERMIT NO
DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT
AND/OR DISPOSAL SYSTEM 1 00 SEPTET NO
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR DRAINFIELD 2 00 INDUSTRIAL
CESSPOOL•DRYWELL -- WASTE APPROVAL
SPECIAL CONDITIONS ONLY 2 00 CHARGES
CONNECTION CHARGE FEE
OWNER'S FEBnT s 1 00
AUTHORMTION TOTAL FEE REIMBURSEMENT FEE
I HAVE TRACTORTTO CONNECT THE HIS DATE AABOVECTED WDESCRIBED ITH THE X EXISTINGEREIN DWELMELING APPROVALS DATE INSPECTOR S SIGNATURE
TO THE PUBLIC SEWER
SIGNED THIS DAY OF NEW HOUSE SEWER
18—
OWNER OR C' CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
1T�f SEPTIC TANK, SEEP,PIT(!)
ADDRESS AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT i 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 SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT 1 AY PROPERLY REGISTERED AND/OR
LICENSED AS REQUIRED BY LOB ANGELES COUNTY AND STATE OF DISCONNECT PLUG AND
ABANDON HOUSE SEWER
CALIFORNIA OR-THAT-I AM THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIAL PROPERTY ` BACKFILL SEP31C TANKS❑
PEEP PrTf CESSPOOL!
SIGNATURE 13
OF PERMITTEE i4el?�01
WILLIAM J PDX COUNTY ENa1N1umR VALIDATION `
BY _ aY9 3 Sm w25 4
2.90 �
- DEPUTY - - DEPUTY '
By BY
® DEPUTY DEPUTY