HomeMy Public PortalAbout5017TEMPLE CITY BLVD_Sewer (2) CESOGE Io-eE
SAAPPLICATION OR PERMI
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION Bu'L
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DESCRIPTION LOT NO Im Z OWNER
MAIL
BLOCK Tnwcr ADDnies 9/6/ �GCf Tf/�D17{'S
NO OF SLOGS /
SIZE OF LOT NOW ON LOT a Cm Tis e-C1/
TEL NO /T- (O/—[[/
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US[ OR �//n DISTRICT NO GROUP MAP R CLSS¢D eY
eUILOIMO• /. ..! pK PO
CONTRACTOR ztA-Gor.�r/.�i �e OT 7•4 D-
ADDRESS ,t41'✓el CO CTION ATA
CITY //G///�//p��. TEL NO •!may /JQG STATION / DEIfH
•TATO MANHOLE R!([RtMC¢ UPPER
REGISTRATION NO COUMY �MweR
No DESCRIPTION OF WORK FE! TYPE OF CONNECTION unaTH FROM
HOUSE SEWER CONNECTING TO Y CURB P L M L TOP L
PUBLIC SEWER 0 is 00 EL
SEPTIC TANK SEEPAGE PIT OR PC NO O
PITS AND/OR BRA
O •1000 CC IMP NO IGS NO
{,
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO
PRIVATE DISPOSAL SYSTEM i]OO C.
CONNECT ADDITIONAL SLOG OR AFFIDAVIT RMY[[ [[[[Y1. RECORD INS" NOF DAT[ O
WORK TO HOUSE S[W[R O iS DO
OVERFLOW SEEPAGE PIT DRAINFIC LO
[XTN CESSPOOL DRYWELL MANHOL72k SSGO d
ALTER REPAIR OR ABANDON HOUR HWY OR 67 WIDENING H
SEWER OR DISPOSAL SYSTEM 59 00 STAT[ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE w"ROYAL
Owwws PERMIT s CHARGES
••„LEL
CONNECTION CHARD[Fi!
AUTHORIZATION I TOTAL FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVAL)
TO THE PUBLIC SEWER DAT[ I • OR S SIGNATURE
SIGNED THIS DAY OF 1s_ �[4
OWNEROR NEW HOUSE SEWER • B•V
OW HER*ADEN T CONNECT ADDITIONAL
ADDRESSBUILDING OR WORK
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION ANDBE"/OIC TANK BEEP PIT(S)
AN
STAT[ THAT THE ABOVE IB CORRECT AND AOR![ TO COMPLY AHO/OR ORwINFI¢LD
WITH ALL COUNTY ORDINANCES AND STATE LAWS RCOULATINO
PLU No[NO AND SEWERS CE96POOL ❑ DRYWELL ❑
1 HCR[BY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR S[W!R OR
LICENSED AS REOUIR[O BY LOS ANGLES CO ND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT THE LEGAL OW OF A INTEND TO DISCONNECT PLUG AND
RBRIDE IN THE AW D SCRIBED [S X IAL P [RTY ABANDON HOUSE SEWER
SIPERM[
0, SACKPILL SEPTIC TANKS ❑
OF }¢KITTLE BEEF PIT(8) ❑ CESSPOOLS
VALIDATION ROBERT A WOOD
C M oI LASH SUPERVISING MECHANICAL ENGINEER
u�C06 0 4 1-� FE828 1 1 0 2 5.00—
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