HomeMy Public PortalAbout5472TEMPLE CITY BLVD_Sewer APPLICATION FOR PERMIT
TSASASD
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGSEWER-SEWAGE DISPOSAL
D7EEA
BUILDING AND SAFETY DIVISION ¢u ILDINa
]OE4/ A L11[d8� Com EDgmBBr ADDR¢ae
VVILLfAM A. IENSW SDP f of euildm9 �— . v
LOCALITY
NEAREST O , ,!
�. CRO88 ST {[
DESCRIPTIO L O OWNER -E ` LJ
MAIL
BLOCK T ADOR[88
2 NO OF SLOGS
•1I¢ OR NOW ON LOT CITY TEL NO [
USE OF DISTRICT NO GROUP MAP E8990 BY
BUILOIN08
!�/� [K PO
CONTRACTOR4,6 AR C 0 iv s 6e /{ 7
ADDRESS CONNECTION DATA
CITY TLL ATION DEPTH
Q' ('� STATE MANHOLE REFERENCE UPPER
REGISTRATION NO o J COUNTY
NO DESCRIPTION OF WORK FEE TYPE OF 0 CONNL 1 LENGTH FROM /
HOUSE SEWER CONNECTING TO ,y\ V CU P L M L TOP L
PUBLIC°EWER Y {°OO 0
SEPTIC TANK SEEPAGE PIT OR JOB XONO
PITS ANO/OR GRAINFIELD O 11000 CO IMP NO UO99401`7
� [�j/�
HODS!SEWER CONNECTING TO TRUNK PERMIT XO ROAD PERMIT NO Y O /
PRIVATE DISPOSAL SYSTEM $300
CONK ADDITIONAL BLDG OR AFFIDAVIT PIN[[ [qu[IR RECORD INSTR NO DATE
WORK TO HOUSE SEWER O jB CO
OVERFLOW SEEPAGE PIT DRAINFIELD
LETN CESSPOOL DRYWELL MANHOLE jS OO
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIO[XIXG
SEWER OR DISPOSAL SYSTEM Y 53M STATE ENCROACHMENT
PERMIT NO
INOUSTRIAL
WABTR APPROVAL
CHARGES
OWNES S PERMIT t z o0
160
CONNECTION CHARGE FE[
AUTHOR1ZPlTION TOTAL FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED WAISTING DWELLING wnO�
TO THE PU°LIC SEWER AP DATE INSPECTOR a 810NATU E
SIGNED THIS pAY OF i6_ �)
J.
OWNER OR F-df/� NEW HOUSE SEWER
OWNERS AGENT- CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
SEPT,CI HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLIGTION AND/OR
TANK SEEP PITIBI
AND STATE THAT THE ABOVE I8 CORRECT AND AGREE TO COMPLY AND/OR DRAINRELD
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND 8[WERS CESSPOOL ❑ DRYWELL ❑
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR ALTER REPAIR 9LWER OR
LICENSED AS REQUIRKSL BY LOS ANGLES COUNTY AND RATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR TX I M TH! L JAL WNER OF AND INTRND TO DISCONNECT PLUG AND
RESIDE IN THE AS [°LflIBi ID[NTIAL PROPERTY ABANDON HOUSE SEWER
81
or PERM BACKFILL SEPTIC TANKS ❑
OF ITT[[ SL[P PIT 181 ❑ CESSPOOLS
/V�ILC ROBERT A WOOD
M 0
CK M o CASH SUPERVISING MECHANICAL ENGINEER
Lp.LO 7 2 ,5 5 G JUL 9 1 0 0 7.00- w