HomeMy Public PortalAbout5235TEMPLE CITY BLVD_Sewer TSA 612DD— CEO" — B/TS APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION eulLDlna g �[
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LOCALITY
LEGALFOR APPLICANT TO FILL IN 'MOOS eT 4t��� A50041
DESCRIPTION LOT NO OWNER
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BLOCK TRACT AODR[J_p '
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OT N ON LOT ITT TEL M
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CONTRACTOR O
ADDRESS CONNECTION DATA
CITY TEL No STATION DEPTH
STATE LIC ' MANHOLE R[I{RI.CC OFFER
LICENSE NO CLASS LOWER
NO DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE[EWER CONNECTING TO Y CURS P L Y L TO P L
PUBLIC SEWER 0 $T 00
OPTIC TANK SEEPAGPIT OR P C NO
FITSAND/OR GRAPHITE.
. 0 {1000 CO IMP NO Job NO
HOUSE SEWER CONNECTING TO THUNK PERMIT NO ROAD PERMIT NO
PRIVATE DISPOSAL SYSTEM 0 $S 00
CONNECT ADDITIONAL SLOG OR AFFIDAVIT RATIO1YTRl1IR RECORD INOTR NO DATE .y
WORK TO HOUSE SEWER O BB OO D.
OVERFLOW SEEPAGE PIT GRAINFIELD QV
EXT. CESSPOOL DRYWELL 0 SS OO
MNOON HO SS XWY OR" WIDENING
SiM[R.pR DISPOBAL SYSTEM I S300 STAT[ENCROACHMENT O
MANHOLE O $T 00 PERMIT NO LL
INDUSTRIAL G..
RT�p WAST[APPROVAL 2
O���YYl\WS PERMT $ H 00 CHARGES —
CONNECTION CHARGE FEE
AUTHOHIZA7ION TOTAL PEE
1 HAV[ AY THIS DATE A CONTRACT WITH THE HEROIN NAMED CON REIMBUMEM[NT F[E
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING AC!<nOVAI�
TO THE FUBLIC SEWER DATE INSPECTOR p SIGNATURE
SIGNED THIS DAY OF IG_
OWMCR OR NEW HOUSE SEWS"
OWNERS AGENT CONNECT ADDITIONAL
AOOREBS_fLf BUILDING OR WORK
I HERESY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION S[FTIC TANK SEEP PIT(B)
•
AND STAT[ THAT TH[ ABOVE 1{ CORRECT AND AOR[[ TO COMPLY ND/OR GRAINFIELD
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
W
PLUMBING AND SEERS CESSPOOL ❑ DRYW[LL ❑
1 H[R[BY CERTIFY THAT I AM PROPERLY REGISTERED ANO/OR ALTER REPAIR SEWER OR
LICENSED AS R[GUIR[D BY LOB ANGLES COUNTY AND STAT[ OF S{WAOE DISPOSAL SYSTEM
CAL. ..,A OR THAT I AM THE LEGAL OWNER OF AND (WEND TO DISCONNECT FIUO AND
R[AIOE IN THE ABOVE DfSCR1B[G R[ I NTIAL P P[RTY DISCONABANDECT PL G AND
•IONATUR[
OF FERMTR[[ WER
BACKFILL f
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VALIDATION cK M . CASH
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3 9 S�MAR -- 1 1 U U 6.00 A`Lo