HomeMy Public PortalAbout4805TEMPLE CITY BLVD_Sewer (2) C[. 6 Is{B APPLICATION FOR PERMI BG j
TSA azo COUNTY OF LOS ANGELES SEWER A E DISPOGS�(L
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION M/J/'I /
JOHN A LAMBIE, COUNTY ENGINEER 1-1 21
COLEMAN W JENKINS SUPT Or BUILDING
FOA APPLICANT TO FILL IN
DESCRIPTION LOTNO BLOCK TRACT
//�T��}} MO O ■ q
SII[ OR LOTZay yE/ HOW OM LLOTOOS CITY T[ MO
US[ 01 D'ST111R M0 GROUP MAP PROCESS SY
BUILDING/
//y�OK PO
COMTRACTOR 16 S G 3 /
ADDRESS" CONNECTION DATA
CITY ITEC NO �'�,' RATION 64 6 •U DEPTH
STAT[ / + LIC MANHOL!REFERENCE / U
LICEM$E NO [LwSS (O OWER
No DESCRIPTION OF O K A. TYPE of corvn[tt1oN LENGTH FROM
HOUSE SEWER CONNECTING TO Y CURB Y L TOP L
PUpLICB[WER • {e oo
tEPTIC TANK GE Plr oR P' No
PITA ANDSGPT DRwINFItLo • {IO OG Co IMP NO Jos rvo
HOU/[$EWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO 1
PRIVATE DISPOSAL BY REM • {Boo CD
CONNECT ADDITIONALBLo6 OR AFFIDAVIT RMY(( [A[[Y(RI RECORD INS" NO DATE V
WORKTO HOUSE/EWER • $3OO OC
OVERFLOW SEEPAGE PIT DRAINFIELD
KXTN CESSPOOL ORYWELL MANHOLE• EB GO
"R OR AMNDON
HOUSEJA�ICATI�
HWY OR ST WIDENING W
SCW[R O^^��'^ • SG GOSTATE ENCROACHMENT
PERMIT NO Z
INDUpTflIAL
���T�p� WAST!APPROVAL
�SO}rllpYr.L�EIS�NS�E pElIM7T so0 CHARGES
AMOAIZATION =FEE y[ CONNECTION CHARGE FE[
1 HAVE AT TNI$ DAT[ A CONTRACT WITH THE M[REICLOJN REIMBURSEMENT F[[
TRACTOR T0.CONN[CT THE ABOVE O[E@IBCO EXISTLING }yam �pTOTHE PUBLIC EEWEIL A"ROVALS DAT[ INBPIROR/SIGNATURE
SIGNED THIS DAV OF _OWNER OR NEW HOUSE/EWER
WNER/AGENT CONNECT ADDITIONAL
ADORES$ BUILDING OR WORK
SEPTIC TANK SEEP PITjS)
1 HERESY ACKNOWLEDGE THAT 1 HAV[ READ THITION AND/OR GRAINFIELD
ANO STATE THAT THE ABOVE 1{ CORRECT AND AORMPLYWITH ALL COUNTY ORDINANCES AND STAT[ LAWTING ❑PLU MBINO AND BEW[R/ CESSPOOL ❑ DRYWELLIH[R[BY CERTIFY THAT IAY PROPERLY REGIST /OR ALTER REPAIR /[WGOR
LICENSED AS REOU IN[D BY LOS ANGLES COUNTY E OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA ON THAT 1 AM THI "GAL OWNER OF AND INTEND TO DI
R[EID[ IN T VC DESCMp[D R[EID[NTIA PRM[RTY N W[
SIGNATURE
OF PERMTTTlC SACKPIBCPTIC TANKS ❑
E[EP PITITS$) ❑ C[/{POOLS
VALIDATION JACK R. ALLEN
CK M O 'ABN SUPERVISING MECHANICAL ENGINEER
r
kr, 4 0 9 Of2 MAR 16 1 0 D 5.0 0;� Y