HomeMy Public PortalAbout4303TEMPLE CITY BLVD_Sewer (2) oLs�'Tr
A64 ,/T3
7BAPPLICATION FOR PERMIT
TBAeAZL COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION eulLolna
ADDRG{
LOCALITY "'e
FOR APPLICANT TO FILL IN CROOES ST
LEGAL
DESCRIPTION LOT NO Ow.a.
MAIL
BLOCK AC ADDRESS
Noor
SLOOY
S12E OF l NOW ON LOT CITY TEL NO
USE OF
BUILDING DISTTR ICT NPa
O GROUP MAP OCESSED BY
I � SK
CONTRACTOR '� Q V`iO
ADDRESS 'LTO .tJ Sr CONNECTION DATA
CITYTA OIL; Barzk TEL NO 3P STATION DEPTH
8 UPMR
CCM{f n0612O 4(L C1Ll!A66 ^ MANHOLE REFERENCE LOWER
NO DESCRIPTION OF WORK ME TYPE OF CONNECTION "NOT"FROM
HOUSE{EWER CONNECTING TO Y CURB P L ML TOPIL
PUBLIC SEWER 0 PC NO d
S DTIC AHK SEEPAGE PIT
PITS AMO/OR GRAINFIELD y V CO IMP NO JOB NO O
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO
PRIVATE DISPOSAL SYSTEM m cc
CONNECT ADDI TIONAL BLDG OR AFFIDAVIT RAIY�� �1�OM{i RECORD INS" NO DATE O
WORKTO HOUSE SEWER O
OVERFLOW SEEPAGE PIT GRAINFIELD
EETN CESSPOOL ORYWtLL MA..OL.0
ALTERR PAIR OR ABANDON HOUSEHWY OR ST WIDENING G.
SEWER OR DISPOSAL SYSTEM O W
STATE ENCROACHMENT Z
PERMIT NO
INDUSTRIAL
�p
a WASTE APPROVAL
O��YY[AYT.}MS PERMIT f &V CHARGES
CONNECTION CHARGE ME
AUTHORIZATION TOTAL BEE
1 HAVE AT THIS OATS A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT F[[
TRACTOR TO CONNECT THE ABOVE DLSCRISEO EXISTING DWELLING
APPROVALS
TO THE PUBLIC SE R �� DATE INSPECTOR S SIGNATURE
SIGNED TH ISDAY OFod,Q✓ 1912
OWNER OR NEW Houst SEWER
OW NCRS ADEN T
CONNECT ADDITIONAL
ADORES{ BUILDING OR WORK
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION =«IC TANK GMP PIT ISI
AND TATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY Y
WITH ALL COUNTY ORDINANCE. AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ ORYW[LL ❑
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR ALTER REPAIR S[W[R OR
LICENSED AS REQUIRED BY LOS ANGLFk_QpUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR VNJ I AM THE LEGAL 09WNENOF AND INTEND TO DISCONNECT PLUG AND
RESIDE IN THE A O E D[SCRIB R[ IOtNT1 L PROPERTY
ABANDON HOUSE{Ewen
SIGNATURE ❑
OF PERMTTTCC BA {[PC TANKS
EP PIT N
SL6P PIT ISI ❑ C666POOLD
XAMATION
CID M O CASH
11^_ 3 9 4 073 DEC 3 1 0 D 1 3 00#