HomeMy Public PortalAbout4367TEMPLE CITY BLVD_Sewer (2) T'A"`G' APPLICATION FOR PERMIT -
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DISPOSAL 1
_ COIINiY OF LOS ANGELFB
MARMEW OF COU= ENGnan
BMWMQ AND SAFETY MINION ADILDING
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NEAREST
FOR AP ANT TO FmUl IN CAOS3 ST
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DESCRIPTION LOT NO OWNER
TRACT MAIL
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OF DISTRIICCTT NO GRO MAP P C
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ATE MANHOLE REFERENCE
MTIONROCOUNTYW,D CR ON OF R FEE 14 1
OUSE SEWER CONNECTING TO opUBLIC SEWER S 00EPTIC 7�LNR SEEPAGE PIT OR T7PE OF CONNECTION LENGTH FROMITS AXb/OR DRAINFIELD 3 00 T CURB P ■ LTO P L.VERFLOW SEEPAGE PIT DRAINFIE.DETH CE39POOL DRTWL�LL YA NHOLE 100 _OUSE SEWER CONNECTING TO P C XO
RIVATE DISPOSAL SYSTEM 100 CO IMP X JOB NoORN 0 NOAADpIT OSEN,IWLAL BLDG OR 1 00 TRUNK PERMIT NO ROAD PERMIT NO
ALTER
OR D19POOSAL ASTDEY HOUSE 1 00 STATE ENCROACHMENT
E PERMIT NO
INDUSTRIAL
�1
WASTE APPROVAL
q O CHARGES
OWNEH'8 PEBWr CONNECTION CHARGE FEE
AUTI OR=TION SOTAL FEE 2 r REIMBURSEMENT FEE
I HAVE AT TN18 DATE A CONTRACT WITH THE HEREIN NAMED COO OVALS DATE INSPECTOR 891GXA7URB
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING NG
TO THE PUBLIC B
SIGNED THIS AT OF IB NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AOEHT BDI LDIMG OR WORK
ADO+ b CTANK SEEP PIT(S)
D OR DRAINFIM _
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL DRYWELL
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
sEEF
1 HEREBY CERTIFY THAT AM PROPERLY ISTERED AND/OR DISCONNECT PLUG AND
LICENSED A8 REOUIRm LOS ANGELES U AMO STATE OF
ABANDON HOUSE SEWER
CALIFORNIA OR THAT I M THE LEGAL OF THE ABOVE
DESCRIBED BI MOPERTT. BACKFILL C TANKS
SIGNATURE PIT
! LS
OF PERYI
®VALIDATION ROBERT A.WOOD
■ G. emu 6UPXRVLSLPIG AM MMICAL ENOINEMIS
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