HomeMy Public PortalAbout5520TEMPLE CITY BLVD_Sewer (2) u/5�"'°` APPLICATION FOR PERMIT
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COIIN7T OF LOS ANGELES SEWER-SEWAGE DISPOSAL i
DEPARTMENT OF COUNTT ENGENEEB
BOD.MNG AND SAFM DMffiON BDORESG p E M OLE' 4 /
AAT ,�L
JOHN A. rRam County � ADRE59
CASSAW D GB>PFar, Sup 1 of BuBdInM LOCALITY G
NEAREST
OH APMCANT TO FlU CROSS n
LEGAL
DESCRIPTION LOT K OWNER
BLOCKI TRA MAIL
SS IO ADDRESS
OF B G9 7
URE OF LOT N 0 T J CITY TEL NO
USE OF _
BUILDIX / D14TRICT NlO GROUP YAP PR ED
5 6
CONTRACTOR O� BE PQ
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ADDRESS f T CONNE=ON DASA
CITY TEL NO A ONDEPTH /
STATE NHOLE REFERENCE
REGISTRATION NO COUNTY
No DESCRIPTION OF WORK
PER y
HORSE SEWER CONNECTING TO
PUBLIC SEWER S 00
SEPTIC TANK SEEPAGE PIT OR TYPE OFC XNECTIOM LENGTH TROY
PITS ALND OR DRAINgFI SEEPAGE
S 00 T CURB P L ■ L TO P
OEKTPF CE39P OPL DRTWELL MANHOLE 0 $S 00
HOUSE SEWER CONNECTING TO P C NO
PRIVATE DISPOSAL SYSTEM B 100 CO IMP NO76 JOB MO
CONNECT ADDITIONAL BLDG OR TRUNK PERMIT NO ROAD PERMIT MO
WORK TO HOUSE SEWER 1 00
ALTER REPAIR OR ABANDON HOUSE STATE ENCROACHMENT
SEWER OR DISPOSAL SYSTEM 1pi1 00 PERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNWS PgRWT CONNECTION CHARGE FEE
AUTHORIZATION FTOTJLL FEE p O REIMBURSEMENT FEE
1 KATE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON APPROVAI3 DATE INSPECTORS SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER
SIGNED THIS DAY OF )B_ NEW HOUSE SEWER
OWNER ORA, 1� CONNECT ADDITIONAL
OWNERS AGENT /r IL BUILDING OR WORK
SEPTICTANK SEEP PIT(S)
ADDRryB ARD OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL DRYWELL
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
IL CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT 1 AN THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDEM PROPERTY. BACKFILL SEPILC TANKS❑
SIGNATURESEE ITS CESSPOOLS
OF PERMITTEE
/ � 0
mr' VMMATIO*/—\ ROBERTA WOOD
Cl ■ o u 1 SUPERVISING MECHANICAL ENGINEER
M3528S JUL1211 D X�250�00 9