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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