HomeMy Public PortalAbout4333TEMPLE CITY BLVD_Sewer DPPARTIIfENT OF COUNTY ENGINEER SEWER—SEWAGE DISPOSAL 1
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF IAS ANGELES q
WILLIAM J. FOXY COUNTY ENDINCER BUILDIl
ADDRESS �J3J T�yl',ni � ' (/ I
FOR APPU NT TO LL IN LOCALITY <=
& "eBT W ZOuILDINeTCeosADDREeB V sa i�
LOCALITY r DISTRICT NO SERIAL NO /, PERMIT NO
NEAREST 5 A .Caa��r S
CROSS ST {NC ECEIVED BY R68tb/6T in1F6611a6 RATE ISSUED
-[OWNER S enc ed -B - 21-Z4-
MAIL USES M OCCUPANCY (BK YAP
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ADDRESS
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CITY -��T[LN0. Ae7`O
CONTRACTOR �'(pI aC lt,
ADDRESS 9 JOB.NO
CITY L TEL NO �
TRUNK PERMIT NO --
REGISTRATION NO �� COU MTY ROAD PERMIT NO
LEGAL STATE ENCROACHMENT
DEBCgIPT10N LOT NO SAp� (1 Vim( PERMIT NO
BLOCK TRACT INDUSTRIAL 1
y WASTE APPROVAL
812E OF LOT 9BX�S"9.d'.'� NOW ON LOTS / CHARGES
BUILDINGS O,h SFJ �.,//Y ` COMNE0T10 ROE FEE
MO DESCRIPTION OF WORK FEE REIMBURSEMENT FE
OUSE SEWER CONNECTING TO
PUBLIC SEWER ® It SSO IS-vRECEIPTNO E IBV
HOUSE SEWER CONNECTING T
PRIVATE DISPOSAL SYSTEM 100
CONNECT ADDITI DUALBLDG OR EXCEPTION RECORDED
WORK TO HOUSE SEWER 1 00
NO GATE BY
ALTER OR REPAIR EB INC
SEWER OR DISPOSAL SYSTEM I00
DISCONNECT AND ARANDO MSEWEB
AMD/OR DISPOSAL SYSTEM 160 CONNECTION DATA
SEPTIC TANK SEEPAGE PIT OR
PITS AND OR DRAINFIELD 2.00 STATION 3 DEPTH
CESSPOOL--0 WELL
SPECIAL CONDITIONS ONLY LW �I MU P EFERENCE ,
TYPE OF CONNECTION LENGTH FROM
OWNERS I 00
Y -OWN& -Mril M L TOP L
PERMIT f
AUTHOR17ATION TOTAL FEE
1 HAVE THUS DATE CONTRACTED WITH THE HEREIN NAMED APPROVALS INSPEcr0 SIGNATURE DATE
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING
DWELLING TO THE PUBLIC SEWERn,
SIGNED THIS�._DAY OF blP t� 19L!f NEW House SEWER
OWNER OR
IS /l�sl6a�r CONNECT ADDITIONAL
OWNERS AGENT BUILDING D WORK
ADDRESS r13 SEPTIC TANKK,,SEEP.PIT(B)
W --- AMD/ORDRAINFIELD
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLI• CESSPOOL 0 DRYWELL
CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER REPAIRSEWEROR
REGULATING PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT I AN PROPERLY REGISTERED
AND/OR LICENSED AS REQUIRED BY LOB ANGELES COUNTY DISCONNECT PLUG AND
AND STATE OF C ORNIAg OR THAT�[I AN THE LEGAL OWN- ABANDON HOUSE SEWER
ES OOP
SI THE ABO HBOBI ES�K^'/" Y71AL 80 ]TIO TA 1'I
F THE �1 SEEP PIT(8) OE88POOLSO
OF PERMITTEE
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