HomeMy Public PortalAbout5422TEMPLE CITY BLVD_Sewer DEPARTMENT OF COUNW ENGINEEB SEINER-SEWAGE DISPOSAL 1
HMSION OF BUnDING AND SAFETY PERMIT APPLICATION
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WILLIAM J. FOX, COUNTY ENGINEER DILotMerADDRESS 12-2. 72',' eZ` n
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FOR APPLICANT TO FILL IN LOCALITY 0G'
BUILDING NEAREST
ADDRESS CROSS ST
LOCALITY DIBTR A RIAL.10 N0�
NEAREST 6 aQ
Cfl088 ST
BFiCEIygy BY Rwft Tu lmpwSw DAT UE c
OWNER `%/JG� /(/ Z7 J
MAILUBE IO OCCUPANCY KPG
ADORE88 ,{n(
CITY TELAO / , �'emS B
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CONTRACTO �j /- 7 /�
CO.IMP MO `(O (� Agg
ADDRESS JOB.NO
CITY L „ �3e TEL N -Lli/. .p1��Y�L TRUNK PERMIT NO
REGISTRATION 10 ja STATE F/•1�A;
COUNTY ROAD PERMIT NO
LEGAL
DESCRIPTION LOT NO 41gQSTATE ENCROACHMENT
PERMIT NO
BLOCK TRACT • ♦�Z-/ TS2. INDUSTRIAL
aTE APPROVAL .►���
812E OF LOT IO OF SLOGS
IOW ON LOT CHARGES
BUIILDINGS �/� CONNECTION CHARGE FE _
NO DESCRIPTION OF WORK FEE
HOUSE SEWERCONNECTIN TO REINBUflBEMEMT FEE
PUBLICSEWER 9 SSB J RECEIPT NO DATE BY
NOOSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 110
CONNECTAODITIOMAL BLDG B E PTION CORDED
WORK TO HOUSE SEWER 100 MO
ALTER OR REPAIR EXISTING DA BY
SEWER OR DISPOSAL SYSTEM I00
ANO ORNDISPOOCT SAL SYSTEM SEWER I00 CONNECTION DATA
SEPTIC TANK,SEEPAGE PIT OR
PITS AND/OR GRAINFIELD 2M STATION ifs DEPTH
CESSPOOL-DRYWELL
SPECIAL CONDITIONS ONLY 208 MA FEREN6
POE W. • Lumm
TYPE OF COMMECTIO LENGTH FROM
OWNERS PERMIT $ I 1 DD cm M L TO P L
AUTHORIZATION TOTAL FEE
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE D ISED EXISTING APPROVALS INGPECTORT SIGNATURE DATE
DWELLING TO TN P BLIO SEWER
SIE;NED THIS_ DAY F_ _19a NEW HOUSE SEWER - sj
OWNER OR CONNECT ADDITIONAL
OWNfRB A gMT BUILDING OR WORK
SEPTIC TANKK,,SEEP.PITO
ADDNE88 AND/ORDRAI NFIELD
1 HEREBY ACNN0IVLEDGE TXA 1 HAVE READ IB APPLI- CESSPOOL❑ DRYWELL
GREE
TO COMPLY WITH ALL CTATE OUNTY ORDINANCESSAND STATE LAWS
REGULATING PLUMBING AND SEWERS ALTER REPAIRp,,SEWEROR
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED SEWAGE DIBPB8AL SYSTEM
ANDDR LICENSED AS REQUIRED BY LOB ANGELES COUNTY DISCONNECT PLUG AMD
D STATE OF CALIFORNIA OR THAT I AN THE LEGAL OWN- ABANDON HOUSE 86MDWER
ER OF THE ABOVE DESCRIS RE DENTIAL PROPERTY BACKFILL IC TANKSat f
SIGNATURE T'�
BEEP PIT(S)[] CESSPOOL$
III OF PERMITTEE _
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