HomeMy Public PortalAbout5708TEMPLE CITY BLVD_Sewer CE A64
iD-03 APPLICATION FOR PERMIT
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COUNTY OF LOS ANGELBS SEWER-SEWAGE DISPOSAL
DEPARTNNIENT OF COUNTY ENGINEER
BUILDING AND SAFETY DMSION BU1LD1na
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LOCALITY 7
NEAREST
P C TO GROSS ST
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DESCRIPTION LOT NO OWNER
MAIL
BLOCK TRACT ADDRESS
NO Of SLOGS
112E OI LOT NOW ON LOT CITY L NO
OBEUSE OF
OF 1 DISTRICT NO OROU MAR P OCESS[O SAY
CONTRACTOR 1J I.+ //(p y
ADDRESS 9 CONNECTION DATA
CITY T[L NO 1141 , STATION DEPTH
STAT! MANHOLE R[F[RiNCE
REGISTRATION NO COUNTY LOWER
NO GESCRIPTI N OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE SEWER CONNECTING TO Y CU AS L ML TOOL
PUSLIC"EWER 0 SO 00 LL
O[RIC TANK p.ElAO[FIT ON R C NO O
FITS AND/OR GRAINFIELD C [1000 CO IMP NO D JOE MO V
HOUSE SEWER CONNECTING TO NK MI PERMIT N0
PRIVATE DISPOSAL SYSTEM 0 [3 00 —
CONN[CTADDITIONALSLDO OR r r rp R[COR IMBTR NO GATE `O
WORK TO HOUSE SEWER
i300
OVERFLOW SEEPAGE PIT GRAINFIELD 4V1
QIITH CESSPOOL DRYW[LL MANHOLE O SOW L
ALTER REPAIR OR ABANDON OUSE HWY OAST WIDENING N
SEWER OR DISPOSAL SYSTEM 0 $3 00STAT[ENCROACHMENT
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
OWNER'S PERmrr s z DO CHARGES
AUTHORIZATION TOTAL FEE 0 [1148�89MKNT
NNECTION CHARGE PRE
1 HAV[ AT THIS DATE A CONTRACT WITH THE H{REIN NAMED CONRE UP FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER PPROVALS DAT{ INSPECTOR O SIGNATURE
SIGNED THIS^yAY OF 19_
OWNER OR / W NOUS{SEWEROWNERS AGENT NNECT ADOITIONALADDRESS ILDING OR WORK
1 HEREBY ACKNOWLEDGE THAT I HAV! READ THIS APPLICATION
AND/OrIC R
SLIE PITIf)
AND STATE THAT THE ABOVE 18 COARECT AND AOR[[ TO COMPLYXD/OR MAINFIELD
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS fBPOOL ❑ ORYW[LL ❑
I
HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED ANO/OR REPAIR B[W[R OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OFWAGE DISPOSAL SYSTEM
CALIFORNIA ON THAT AM THEA OWNER OF AMD 1 [NO TOSCONNECT PLUG AND
RESIDE IN TH! AMOV [SC 1 pO ID[NTIAL PROPS ANDON HOU"[SEWER
SIGNATURE CKFILL SEPTIC TANKSOF PERMITTEEEP PIT($) ❑ CESSPOOLS
VALIDATION ROBERT A WOOD
CK M o CASH SUPERVISING MECHANICAL ENGINEER
U. 08603E f1Ar 8 1 0 D 5.00"
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