HomeMy Public PortalAbout5329TEMPLE CITY BLVD_Sewer DEPAIVKhMU T OF COUNTY ENGU EEN SEWER—SEWAGE DISPOSAL 1
DIVISION OF BUILDING AND SAFETY ! PERMIT APPLICATION
COUNTY OF LOS ANOELES ' _
WILLIAM J. FOX, CDuNTY ENOINFFR BUILDING
ADDRESS r
FOR APPUCA TO FILL LOCALITY
BUILDING NEAREST
ADDRESS d CROSS ST
LOCALITY DISTRICT NO SERIAL NO .{PEERMIT NO
NEAREST 5 A ..y�/O S
CROSS ST a24.
17 7 R!SPVED BY BIRO for latPectIm A SU
ISE
OWNER
MAIL ^ - - . 0 _ UB^E ZON OCCUPANCY BN MAPOT
CITY � TEL NO / V( / �
CONTRACTOR DO IMP NO
ADDRESS 0
100.NO
ev
Of- r r TEL NO 71444OU TRUNK PERMIT NO
i
REGISTRATION NO COUNTY ROAD PERMIT NO
LEGAL S STATE ENCROACHMENT
DESCRIPTION LOT NO i PERMIT NO
BLOCK TRACT INDUSTRIAL
WASTE APPROVAL
SIZE OF LOT`A ice. Y�sf'�'�' MOW ON LOT CHARGES
USE OF
BUILDINGS CONNECTION CHARGE FEE
NO DESCRIPTION OF WORK FEF REIMBURSEMENT FEE
HOUSE SEWERCO 1 O
PUBLIOSEWER @ S 000 RECEIPT NO DATE BY
NOOSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 1 MI
IINECTADDITIONAL BLOB OR EXCEPTION RECORDED
WORK TO HOUSE SEWER 1 00
A TEROR REPAIR EXISTING N DATE BY
SEWER OR DISPOSAL SYSTEM Im
AND/ORDISCONNECTPOND ASBANDON SEWER I Do CONNECTION DATA
SEPTIC TANK % PA R
/1T8 AND/ORD LD Z.00 uV STATION DEPTH
CESSPOOL--0RYWELL
SPECIAL CONDITIONS ONLY 200 MANHOLE LOWER
I TYPE OF CONNECTION LENGTH FROM
OWNERS PERA/tT $ I I Oo Y CURB PL N L TO P L
AUTHOMATION TOTAL FEE I z 160 _
CO TRACTOR TAVE THIS O DATE CONTRACTED
ABOVE DESCRIBED THE EXISTMED
ING APPROVALS INSPEOTOWSSIGNATURE DATE
DWELLING TO THE PUBLIC SEWER
SIGNED THIS __-DAY OF � 19- NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT __ _ _ —. BUILDING OR W
TA
ADDRESS _
SEPTI
D OR ORA e _ W
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI- CESSPOOLO DRYWELLEJ
CATION AND STATE THAT THE ABOVE 18 CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER �
REGULATING PLUMBING AND SEWERS SEWAGE B
DISPBREPAIRSEWER EWER OO M
1 HEREBY CERTIFY THAT I AN PROPERLY REGISTERED
AND/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY DISCONNECT PLUG AND
AND STATE OF CALIFORNIA OR THAT 1 AN THE LEGAL OWN- ABANDON HOUSE SEWER
ER OF THE ABOVE DE BIDED RESIDENTIAL PROPERTY BAOKFILL C
TANK-
SIGNATURE
BEEP PIT(S)[] CESSPOONO
O _ w/ �
OF PfiRYITTEE �L
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