HomeMy Public PortalAbout5318TEMPLE CITY BLVD_Sewer (2) `
10
..D 62APPLICATION FOR PERM
T AS
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION F
DING
JOHN A LAMBIE COUNTY ENGINEER RIBS
COLEMAN W JENKINS SUPT OF BUILDING
ALITY
MST !
FOR APPLICANT TO FELL IN BE ST
LEGAL',D[pCRIPT
LOT No BLOCK ' - TRACT R[ /
Rao no or SLOGS
SIZE OF LOT NOW On LOT CITY NO
Up[ OF
pUILO1NOp DISTRICT NO GROUP MAP/J PROC"BE BY
A.
J / BK P�
CONTRACTOR _ Q ,V)
ADDRESS Q FF CO CTlON DATA
CITY TEL NO STATION DEPTH
STATE LIC MANHOLE wprLRCnC[ UPPER
LICENSE NO I=A// LOW"
NO DESCRIPTION OF WORK I[[ TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y CURS P L M L TO P L d
PUBLIC SEWER O $BOO O
SEPTIC TANK SEEPAGE PIT O" PC NO
PITS ANO/OR GRAINFIELD O $1000 CO IMP NO JOB NO LJ
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO O
PRIVATE DISPOSAL SYSTEM O $3 00
CONNECT ADDITIONAL BLDG OR AFFIDAVIT I /AIFO uA[R[01 RECORD INBTR NO OATC F
WORKTO H OUSES[WER O $300 (W)
OVERFLOW SEEPAGE PIT GRAINFIELD a
E%TN CESSPOOL DRyjp0%jkA.HOLZ O $S OO h
ALTERq PAIR OR GUS[ HWY ORST WIDENING Z
6 EWER QiGYSMISA Y [N O S300 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
WAST[APPROVAL
OT[F[TOp•O CH O[/
TTLYms PEMT f z OG
AUTHORIZATION TOTAL FEE CONNECTION CHARGE F[[ `
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
HAVE
TO CONNECT T E ABOVE DCSC ISED EXISTING DWELLING
TO THE PU pLIC /tea /� APPROVAL$ DATE INSPECTOR a SIGNATURE
SIGNED THIS AY 10
OWNEROR Hou/ES[WER
OWNERS AGENT
NN ECT ADDITIONAL
ADDRESS UILDINO ON WORK
I HERESY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION PTIC TANK SKIP PIT(S)
AND/OR GRAINFIELD
AND BTATE THAT THE ABOVE IS CORRECT AND An TO COMPLY
WITH ALL COUNTY ORDINANCES AND BTATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ ORYW[LL ❑
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR ALTER REPAIR /EWER OR
LICENSED A8 REQUIRED BY LOS ANOLX5 COUNTY ANO STAT[ OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF AND INTEND TO DISCONNECT FLUO AN
O
RESIDE IN THE AB D[SCRI/ REeIDCNTI PROPERTY
ABANDON HOUSE a WED
610NATUI
01 P[RMTfTE BACKFILL SEPTIC TANKS ❑
6IEP PIT(W ❑ CISSPOOU
/-YAIIDATION JACK R ALLEN
M o cwpH SUPERVISING MECHANICAL ENGINEER
G90a:- ..:4L1010 D 5.00-
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