HomeMy Public PortalAbout5522TEMPLE CITY BLVD_Sewer (2) T.A:A� A-rrA `µAPPLICATION FOR PERMIT
CXooM"9"u COUNTY OF LOS ANGELES
SEWER-SEWAGE DISPOSAL
DUAHTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION ADDRESS
JOHN A. Lumm Co®l7 Ewfnew ADDRESS L E 'L /
D GEse>b, SWt d BRAamM LOCALITY 07
FOR TO FII.L NEAREST
CRO!!n
LEGAL
DESCRIPTION LOT 0 0
BLOCK TRA MIF' /� MAIL
ADDRESS
SIZE OF LOT O JW NO OF BLDG! 1p�
NON ON LOT CITY TEL NO
DUE OF `j�'F DISTRIC=NO GROUP YAP P ESS
BUI LD[NO/ a/
D BR PG
CONTRACTOR
ADDRESSCONNECTION DATA
CITY TEL NO [/ I/e ON DQ H
3 0STATE Y NNOLE CE P
REGISTRATION NO COUNT?
N gE�R/IPTION OF WORK E
PUBLIC SEMERCOHNECTING TO 9
FPTIL T NK,SEEPAGE PIT OR T 7TFE OF CURB OM P L LENGTTONP OY /
PITS AND ORA
R DT N FIELD $!00
OVERFLOW SEEPAGE PIT DRAINFIELD
EZTN CESSPOOL DRYWELL YANNOLE S 00
HOUSE HEWER CONNECTING TO P C NO
PRIVATE DISPOSAL SYSTEM $1 00 CO IMP NO JOB NO
CONNECT ADDITIONAL BLDG OR TRUNK PERMIT NO ROAD PERMIT NO
WORK TO HOUSE SE��IWIER !1 00
ALTER ORPAIRORtBANTEY HOUSE 1 00 STATE ENCROACHMENT
"
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNWS F®MIT CONNECTION CHARGE FEE
AUTHORMATION I TOTAL FEE Or'JJ REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON APPROVALS DATE INSPECTOR S SIGNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC!EWER
SIGNED THIa ^AY OF% )S_ NEW HOOSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK is
SEPTICTANK SEEP PITIS)
ADD KM AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION ""
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COYPU CESSPOOL DRTWELL El
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT I AN PROPERLY REGISTERED ARD/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 RESIDENYAy PROPERTY. BACKFILL SEP-MC TANKS❑
SIGNATURE SE PITS CE! 0
OF PERYI /lam
mF {IAI,IDATIOI'Y --N ROBERT
�fWO
6D
■ o SUPERVISING MECHANICAL.K@OIN6JR
L&352PS -U121 1 D 25.00