HomeMy Public PortalAbout5537TEMPLE CITY BLVD_Sewer (2) 75A 6420•CE50t-10-71 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BulLoln. 5537Temple Ci Blvd
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LOCALITY T City
WFOROR APP LICA�NyT,T+O FIoLL IN ��o�ols/TQ]uVo ooy�kq��[} /�}�fp/Y()LOT NO Ort'10D ,�Ol OWNER LAYfC1S 0[W1f13YYf` (110 iTRACT Njeei(MView AcreS ADDRES%% j�� ^, T le Ci •BlvdTI- HOTBOIOWONLOTLj8T'TION
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cITY SO San GGab�E�r�Ij�f� el3�Nrpo 541,7 DertH
STATELICENNO LYJ/`-T CLASS LICB-I MANHOLE REFERENCE n PPCR
NO DESCRIPTION OF WORK FE[ iYP¢OF CONNECTION LENGTH FROM
IHOUSE SEWER CONNECTING TO Y CURB P L ML TO P L
PUBLIC SEWER 0 $7 00
SEPTIC LANK E[[PAOE PIT OR �j rocs
NO
PITS ANO/OR GRAINFIELD 0 f1000 CO IMP NO / (./ JOB NO
HOUSE[EWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT
PRIVATE DISPOSAL SYSTEM 0 fi 00
CONNECT ADDITIONAL BLDG ORL
AIPIDAVIT Ru[u [A[[R[Rf R[CORO [NO
TR NO DAT[ u
WORK TO HO USE SEW ER 0 [300
OVERFLOW SEEPAGE PIT DRAINFI[LD DE
E%TN CESSPOOL DRYW ELL 0 SSW O
ALTER REPAIR OR ABANDON HOUSEHWY ORST WIDENING F
SEWER OR D18PO8AL SYSTEM 0 13 00STAT[ENCROACHMENT w
MANHOLE 0 $T 0PERMIT NO a
INDUSTRIAL N
��PI�}�p WASTE APPROVAL
OPY1 EES PERMIT CHAROEB
AUTHORIZATION TOTAL FEE CONNECTION CHAR.[FEB
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED N WK
TO THE PUBLIC B [ Iy /SQL O` -�C "PROVAM D T ECTO OIGNATURK
SIGNED THIS D V OF \AiY YO 19_
OWNER OR GIIILTJ_ NEW HOUS[SEWER
.WNE AGEnT (TCONNECT ADDITIONAL
ADDREB city Blvd T Ci BUILDING OR WORK
I HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION A.D/.SEPTIC
TANK BEEP PIT(S)
ANG STATE THAT TH[ ABOVE IS CORRECT AND AGREE TO COMPLY AND/OR ORAINPIELD
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING Er PLU MEING AND SEWERS - CESSPOOL ❑1 HEREBY CENT" THAT 1AM PROPERLY REGISTERED ANO/OR ALTER REPAIR LICENSEDASREOUIRE. BY LOS ANGLESCOUNTY AND STATE OF SEWAGE DISPOSCALIFORNIA OR THAT I AMTH[ L[OAL OWNER OF AND INTEND TO DISCONNECT PLRESIDE IN TH[ AB DEe ED R[SIDCNTI PROPERTYABANDON HOUSIGNATURE
OF P[pMTI[ BA ILL 8CITI}P� DISE[ P IT ISI ❑
VALIDATI EK M O CASK
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