HomeMy Public PortalAbout4333TEMPLE CITY BLVD_Sewer (2) i �
642D'° APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL -�
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
JOHN A LAMBIE COUNTY ENGINEER ADDRESS
COLEMAN W JENKINS SUPT or BUILDING
LOCALITY
FOR APPLICANT TO MAAREBT
FILL IN CROSS BY
(PRINT OR TYPE ONLY)
LEGAL
DtfCRIPTION LOT NO OWNER
MAIL
[.LOCK TRACT ADDRESS
NO OF {LOOS
SIZE OF LOT NOW ON LOT CITY O
USC W
BUILDINGS DISTRICT N° GROUP CLA33 MAI ROLE ED BY
VWANHOLE�' E4NCE
PBSOADDReESCONNECT`_ DLrTHCITY _ Ej�. TtL NO ISTATE LC MCCLICCN3[ NOCABB LOWER
NO DESCRIPTION OF WORK ILL CON NECTION LENGTH FROM
HOUSE eLWtR CONNCCTINO TO CUR[. P LPU{LICSCWLRSEPTIC TA K St PAGE PIT OR PCNO ^ ZO7
11"AND/OR DMINFILL° O {I000 JOp NO GHOUSE"WCR CONNECTING TO T NO ROA[.PERMIT NO 1
PRIVATE DISPOSAL SYSTEM 0 83M O
CONNECT ADDITIONAL SLOT OR AFFIDAVIT I B11TEI ELE[gv RECORD INSTR NO DATE V
WORK TO HOUSE SEWER C $300
OVERPLOWMEPAO[PIT DRAINFI[LO m
ELTN CEBBPOOL ORYW[LL MANHOLE C Se 00 O
ALTER REPAIR OR ABANDON HOU{ HWY OR ST WIDENING
SEWER OR DISPOSAL SYSTEM SOW STATE ENCROACHMENT
"KNIT NO d
INDUSTRIAL //l� y
WASTE APPROVAL Y 1
C}�p CHARGES
O TTTLT1\ws I
PmmT , °O CONNECTION CHARGE FEE $
AMOFMTION PE1901-
TOTAL E
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON RLIM.UR.[MSNY RE
TRACTOR TO CONNECT THE ABOVE D[SCRISID CASTING DWELLING A!l80VA
TO THE PUBLIC {EWER DAT[ [CTO S IGNATURK
SIGNED THIS DAY OFSIGNED THIS DAY 19—
OWNEROR NEW HOUSE SEWER �I
OWNER{AO[NT
CONNECT ADDITIONAL
ADORES{ BUILDING OR WORN
pCPTIC TANK SEEP PIT IS)
I X[RISY ACNN OWLLDOC THAT 1 HAVE READ TXIB APPLICATION AND/OR MAINFI[LO
AND STATE TNAT THE ABOVE IS CORRECT AND AORte TO COMPLY
WITH ALL COUNTY OROINANC[S AND STAT[ LAW{ REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWCL.L ❑
1 HERESY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
LICENSED AS REOWRCD BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT 1 AM THC L[OAL OWN MTEND TO OIBCONNECT PLUG AND
RESIDE IN [ DE IBCO RCSID TIAL PROP! ApANDON HOUSE B[W LR
IIONATUR[
01 PERM"E BACNI III SEPTIC TANK[.
6[tP PIT CESSPOOLS
_ VAMATIJACK R. ALLHN
CK M D CASH 'SUPERVISING MECHANICAL ENGINEER
LACo 4 3 3 1 FEB 1 0 D 1 0.0 0� g