HomeMy Public PortalAbout5135 SULTANA AVE_Sewer__ TEMPLE CITY
6AG4 lB-BB APPLICATION FOR PERMIT
CESOS I
COUNTY of LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIJONBUILDING
WMALANAIS County EngpADDRESS
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❑ BOUNTY MANHOLE REFERENCE UPPER
ND DESCRIPTION OF WORK FEETYPE OF CONNECTION LEN THF MHOUSE SEWER CONNECTING TOY CURD P L M L TO P L�'�PUBLIC SEWER O [ 00SEPTIC TANK SEEPAGE PIT OR P C NO OPITS AND/OR GRAINFIELD [ CO IMP NO JOS NOVHOUSE SEWER CONNECTING TOTRUNK PERMIT NO ROAD PERMIT NOPRIVATE DISPOSAL SYSTEM �'
CONNECT ADDITIONAL SLOG OR AFFIDAVIT S.IYO EII[REIITRECORD IMSTR NO DATE `O
WORK TO HOUSE SEWER B]DO
OVERFLOW SEEPAGE PIT DRAI"FIELD LLV/
EXTN CESSPOOL ORYWELL MANHOLE O EB OO N
ALTER R PAIR OR ABANDON HOUSE HWY OR ST WIDENING Z
SEWER OR DISPOSAL SYSTEM O E]00 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
PRT�p� WASTE APPROVAL
O��YYAN✓�L S PERMR f 2 00 CHARD"
A=O=ATION I TOTAL FEE 7 00 CONNECTION CHARGE FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPH�VAL3
TO THE PUBLIC SEWER DATE INSPECTOR B SIGNATURE
SIGNED THIS DAY OF IG_
OWN"OR NEW HOUSE SEWER
OWN ERB AGKNT
CONNECT ADDITIONAL
ADDRESS SU ILDINO OR WORK
I HERESY ACKNOWLEDGE THAT I HAVE ROAD THIS B[PTIC TANK BE" PIT(EI
APPLICATION AND/OR GRAINFIELD
AND STATE THAT THE ABOVE ID CORRECT AND AORE[ TD COMPLY
WITHALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUM SING AND SEWERS C[BBPOOL ❑ DRYW[LL ❑
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
LICENSED AS REQUIRED BY LOB ANGLES COUNTY D STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF "D INTEND TO DISCONNECT PLUG AND
RESIDE IN THE ABOVE D[ RID[ RESIDENTIAL OP A BANDON HOUSE SEWER
61ONATURQ BACKFILL SEPTIC TANKS
OF PER..
TTEC SCEP PIT(BI ❑ CQBDPOLS
��/ALROBERT A WOOD
M 0 C
, ) M O CASH SUPERVISING MECHANICAL ENGINEER
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