HomeMy Public PortalAbout5448TEMPLE CITY BLVD_Sewer DFWAETMENT OF COUNTY ENGINIDt I SEWER--SEWAGE DISPOSAL '1
DIVISION OF BUnMrNG AND SAFETY MIT AP L CATION
COUNTY OF LOS ANOVA !, p
WILLIAM J. FOX. COUNTY ENGINEER ApOpD �� T4 7 ,Z
FOR APPU ANT TO FILL N LOCALITY G /�{�
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OWNER �.�/�AV`
ADDRESS ZO OCCUPANCY SIX IRS
CITY T[LN0. jos
'e9 �Z Z
CONTRACTOR SAV CO.IMP NO 6 Z
ADDRESS JOB.NO. —
CITY T[L.NO. l TRUNK PERMIT NO
RATE
REBI87RATI0N NO COUNTY ROAD PERMIT NO
DESCRIPTION LOT M STATE ENCROACHMEN
PERMIT NO
BLOCK TRACT INDUSTRIAL
WASTE APPROVAL
SIZE Of LOT NO OF GLOBAL CHARGE
MOW ON LOT
USE OF _ / A
BUILDING V /� . CONNECTION CHARS EE
NO DESCRIPTION OF WORK FEE REIMBURSEMENT FEE
UE SEWER CO I
PUBLIC SEWER @s 860 �Y� RECEIPT NO DATE BY
HOUSE SEWERCONNECTING TO
PRIVATE DISPOSAL SYSTEM 100
MNEOT
ADDITIONAL L 0.08 I EXCEPTION CORDED
ORK TO HOUSE SEWER Igo / A�/
ALTER OR REPAIR EXISTING NO DA BY
SEWER OR DISPOSAL SYSTEM 100
DISAND/ORSOISPOSAL SYSTEMA SEWER 100 CONNECTION DATA
S PTIC TANK,SEEPAGE PIT OR
PITS AND OR GRAINFIELD LOO STATION Z • DEPTH Z
CESSPOOL—UHYWELL
SPECIAL CONDITIONS ONLY 200 7 A E►EREM
I / P ER r U�
TYPE OF DSNNECTI LENGTH FROM
OWNERS PERMIT I P �OORB P L M LEL
TO P L
AUTHORIZATION TOTAL FEE
1 HAVE THIS DATE CONTRACTED WITH THE HER NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR' IGNATURE DATE
DWELLING TO THE PUBLIC SEWER _T /
SIGNED THIS AY OF Iq NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AS _ BUILDING OR WORK
SEPTIC TANKK,,SEEP.PIT(8)
ADDRESS AND OR DMINFIELD
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLI• CESSPOOL DRYWELL
CATION AND STATE THAT THE ABOVE 18 CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STAT[ LAWS ALTER REPAIR SEWER OR
REGULATING PLUMBING AND SEWERS SEWAGE DISPO61L SYSTEM
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED
AND
LICENSED AS REQUIRED ANGELES COUNTY DISCONNECT PLUG AND
AND STAT[ OF CALI NIA OB T AM TJLE LEGAL OWN- AMDON HOUSE SEWER
ER OF THE AROY [MTI ROP[NTY L ANKann
SIGNATUREIn 8 PIT(8)� CHBSP0OLS
OF PERMITI
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