HomeMy Public PortalAbout5708TEMPLE CITY BLVD_Sewer (2) C[BOB 10a0E D APPLICATION FOR PERMIT
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COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENS OF COUNTY ENGINEER
BUDDING AND SAFETY DMSION BUILDING
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CONNECT THE ASV[ DESCRIBED ERISTINO DWELLING AI'I'AOVA�
TO THE PUBLIC StWKR DATE INSPECTOR$SIGNATURE
SIGNED THIS DAY OF 19_
OWNEROR MEW HOUSE SEWER
OWNERB ADHNT CONNECT ADDITIONAL
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I N[R[BY ACKNOWLEDGE THAT I HAVE REAP THIS APPLIGTION AND/OR MAINFIELD
AND tTATE THAT THE ABOVE IS CORRECT AND AGR[[ TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUM BIND AND SEWERS CESSPOOL ❑ DRYWELL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED ANO/OR ALTER REPAIR BEWEROR
LICENSED AS REOUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPCSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF AND INTEND TO DISCONNECT PLUG AND
BESIDE IM THE ABOVE DESCRIBED RESIDENTIAL PROPERTY ABANDON SPOUSE0 AND
WER
SIGNATURE
OF PUIMIT[ES BACKFILL SE T TANKS ❑
BEEF PITfB CESSPOOLS
VALMATI ROBERT A WOOD
CK M o cABH SUPERVISING MECHANICAL ENGINEER
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