HomeMy Public PortalAbout5716 NOEL DR_Sewer__ s
TEMPLE CITY
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cosoo a ss APPLICATION FOR PERMIT
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COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTNB;NT OF COUNTY ENGINEER
BUILDING AND SAFETY DMSION BUILDING
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meas ADDRESS
CKSS 7 D GItiFPIIf S Countv of B+alding
LOCALITY Ae
NEAREST ip
FOR APPLICANT TO FILL IN CROSS ST
LEGAL
DESCRIPTION LOT NO OWNER
BLOCK TRACT MAIL
ADDRESS
NO of BLDGS Q
SIZE OF LOT D NOW ON LOT CITY TEL NO a�
USE OF Ig A
BUILDINGS A p DISTRICT NO [GROUP
ROMAP PROCE8 BY
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CONTRACTOR �+ a.�
ADDRESS 57 �4 A F.(CS QA o 7 CO CYTON DATA
CITY W L/I �� TEL NO �� 'L fps Z, STATION DEPTH
JOE? STATE MANHOLE REFERENCE UPPER
REGISTRATION NO v C?� COUNTY LOWER
NO DESCRIPTION OF WORK FEE
PUBLIC SEWECONNECTING TO $3 00 -9 2X P-lailt 917
SEPTIC T�NK SEEPAGE PIT OR Y TYPE OF CONNCURBECTIONP SEL TO 6 p`OM
PITS AND OR DRAINFIELD SS 00
OVERFLOW SEEPAGE PIT DRAINFIELD
EXTN CESSPOOL DRYWELL S200
HOUSE SEWER CONNECTING TO P C NO
PRIVATE DISPOSAL SYSTEM @ sloo CO IMP NO JOB NO
CONNECT ADDITIONAL BLDG OR TRUNK PERP T NO ROAD PERMIT NO
WORK TO HOUSE SEWER SI 00
ALTERR RREPPAIRR OR ABANOEM HOUSE Sl o0 STATE ENCRO CNMENT
DISPOSAL
PERMIT NO
INDUSTRIAL
WASTE APPROVA
CHARGES
OWNER S PERKY 2 00 CONNECTION CHAR
AUTHORIZATION rTOTAL FEE REIMBURSES FEE
CON F
TRACTOR To CIONNECT THE ABOVE DESCRIBED EXIST NGDATE A CONTRACT WITH THE HEREINAMED DWEL DWELLING PROVAM DATE INSPE S SIGNATURE
TO THE PUBLIC SEWER
SIGNED THIS AY OF +9_ x HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
TANK SEEP
ADORES g SEPTNR DRAINFIELDPIT(S)
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL ❑ DRYWELL
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS ALTER REPAIR SEWER OR
SEWAGE DISPOSAL SYSTEM
1 HEREBY CERTIFY THAT i AN PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AN THE LEGAL OWNER OF THE ABOVE
DESCRIBED RESIDENTIAL PROTY BACSEEFPIT SEPT[❑CANKS ❑!.S
SIGNATURE �,.
OF PERYITTE
®r _ VALIDATION ROBERT A WOOD
CE. M 0 CASlI 8UPBRV18lN+i MECHANICAL ENGINEER
[;,I071A4t8 --)EF30 E o 300 r
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