HomeMy Public PortalAbout5530-5605TEMPLE CITY BLVD_Sewer 76A 542D-CES08 -10-71 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION Sul DING Z 5
ADDRESS
LOCALITY G
FOR APPLICANT TO FILL IN NEAREST O CSI
CROSS QT
LEGAL
DCtCRIPfION LOT NO / OWNER
M
3 A AIL
BLOCK TRACT V MAILADDRESS
NO OF BLDGB
SIZE OF LOT NOW ON LOT CITY TEL NO
USE OI
BUILDINGS DISTRICT NO GROUP MIP 7E83CD BY
GONTRACTOR `
ADDRESS O a CONNECTION DATA
CITY /� /!�T[L STATION DEPTH
STATE {, `/ C ASS LIC `L MAryHOLE Rf F[RENCE �l f� UPPER
LICENQE NO .JJ
NO DESCRIFTI N F WORK F[[ TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO U Y CURB P L M L TO P L
PUBLIC SEWER Q $T DO
SEPTIC LANK SEEPAGE PIT OR PC N��J -7-1 -1/
PITS ANO/OR GRAINFIELD Y {IO OO CO IVP NO JOSH L
HOUSE SEWER CONNECTI NO TO TRUNK PERMIT HO ROAD PERM NO d
PRIVATE DISPOSAL SYSTEM O t3 00 O
CONNECT ADDITIONAL BLDG OR AFFIDAVIT I WAIVE[1 1LEEII1RT RECORD INSTR NO DAT[
WORKTO H OUSESEWER 0 E3 GO V
OVERFLOW SEEPAGE PIT GRAINFIELD O
SKTN CESSPOOL DRYWELL C SSW HWY Ofl ET WIDENING
ALTER REPAIR OR ABANDON HODS[
S EWER OR D ISPOSALSYSTEM [300 STATE ENCROACHMENT W
MANHOLE 0 fT 00 PERMIT NO a
N
INDUSTRIAL Z
���}�p WAST[APPROVAL
OTYtWws PERMIT { 9 00 CHARGES
AUTH0f=TION 70TAL FEE G U CONNECTION CHARGE FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER APPROVALS TE INSP TOR'SIO ATUR[
SIGNED THIS DAY OF 19_
OWNER OR NEW HOVEL SEWER
OWNERS AGENT
CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
1 HERESY ACKNOWLEDGE THAT I HAVE READ TRIS APPLICATION SEPTIC TANK BEEP PIT(S)
AN iTATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY '(ND/OR OR
_
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWCLL ❑
I HERESY CERTIFY THAT I AM PROPERLY REGISTERED ANO/OR ALTER REPAIR SEWEROR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STAT[ OF SEWAGE DISPOSAL SYSTEM
GLI FORNIA OR THAT I AM THE LEGAL OWNER OF AND INTEND TO DISCONNECT PLUG AND
RESIDE IN THE ABOVE DESCflIBED R[SI ryTIAL PRO RTY ABANDON HOUSE SEWER
SIGNATURE
OF PERMiTT EE IS ,ILL SEPTIC TAryKB ❑
SEEP PITIS) 'POOLE
VALIDATION CK M 0 CASH
l , 1069 � FEB1610D 10.00- q