HomeMy Public PortalAbout5530-5605TEMPLE CITY BLVD_Sewer (2) Tea a+zD-ceeop- lo-T1 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGJA
BUILDING AND SAFETY DIVIILDING
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FOR APPLICANT TO FILL
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NO OI BLOODSIZE OF LOT NOWONLOTY TEL MO
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BUILDINGSSR PB \CONTRACTOfl v2CDADDRESS TQa M- kCONNECCITr E TEL No yTION ;:2 J -1 DEPTH
STA /( ( LICM MOLE ROSI�EfltMC[ UPPER
LICENSE NOLA[tNO DE9CRI PTION OF WORK F[CTYPE OF CONNECTION "MOTH FROM
HOUSE SEWER CONNECTING TO CURB PL MLTOPL
PUBLIC SEWER 0 fT 0SEPTIC TANK SEEPAGE PIT OR JC N /jPITS AND/OR DRAINFI[LO 0 EI00IMP NoJOBN �C 2HOUSE SEWER CONNECTING TOUNK PtRNIT NO pOAD P{KNIT NO aPRIVATE DISPOSAL SYSTEM 0 E30
CONNECT ADDITIONAL SLOG ON AFFIDAVIT PCnu 9"10[4 RECORD INST11 NO DAT[ O
0
WORK TO MOUSE SEWER 0 33 GO
OVERFLOW[[[PAGE PIT GRAINFIELD �.
[%TN CESSPOOL DRYWCLL 0 [900 O
ALTERREPAIR OR ABANDON HOUSE HWY OR ST WIDENING
SEWER OR DISPOSAL SYSTEM 0 5300 STAT[ENCROACHMENT ty'
MANHOLE 0 fT 00 PERMIT NO a
INDUSTRIAL
R}�p
WAST[APPROVAL
O{��TTNEFrS FCRIIDT j e 00 CHARGES
AUTHORIZATION TOTAL FEC 00
CONNECTION CHARGE FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON ReIMBURSEM[NT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED �DTING DWELLING APPROVALS TO THE PUBLIC SEWER DATE INYe OR Sp N TU RE
SIGNED THIS DAY OF 10_
OWNER OR NEW HOUSE SEWER
OW NCR5 AO[MT CONNECT ADDITIONAL
ADDRESSBUILDING OR WORK
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND/OR
BEEP PITIU
ANO STAT[ THAT THE ABOVE IS CORRECT AND AOR[[ TO COMPLY '•RD/OR DRAINIIELO
WITH ALL COUNTY 0ROINANCf6 AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ ORVW[LL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
LICENSED Ap RCOUIREp BY LOp ANGI[S COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALI FORNI. OR THAT 1 AM TME LEGAL OWNER OF D IM[MD TO DISCONNECT PLUG AND
RESIDE IN THC ABOVE D[ RI ED IDCNTI ABANDON HOUSE SEWER
SIGNATURE SACKIILL SEPTIC TANKS ❑
OF P[RMTTT[[ DEEP PIT IS) ❑ so COLD
VALIDATION CK M o CASH
LArn 1 0 6 81j 17E8 16 1 0 D 1 0.00-
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