HomeMy Public PortalAbout5633 D & E SULTANA AVE_Sewer__ TEMPLE CITY
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CRROB a as APPLICATION FOR PERMIT
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COUNTY OF LOS ANGELES SEWERJS A-G DISPOSAL y
DEPAHrMm OF COIINTY ENGmEm
BUIIAING AND SAFETY DIMON BUILDING
DRESS
AUILDIN
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LEGAL
DESCRIPTION LOT NO OWNER
BLOCK TRACT ✓I W ADDRESS
91Z80F LOT XOW OMAIL
N LOTS ITf L NO ✓
USE OF
BUILD IXG! D �NO GROUP BE YAP ro
ROCESSED B
CONTRACTOR 8
ADDRESS CONNECTION DATA
CITY TEL NO 63. STATOR DEPTH
ATE MANHOLE REFERENCE UPPER
REGISTRATION NO �0O COUNTY LOWER
No TIIIgE DESCRIPTION F WORK FEE
PIOIBLICSE WERCONNECTING TO 59 OO `
SEPTIC TANK SEEPAGE PIT OR TYPE OF CONNECTION LENGTH FROM
PIT!AXD OR DMINFIELD SS OO Y CURB P L Y TO P L -
OYERFLOW SEEPAGE PIT DRAINFIELD
ERTN PDL DR
YWELL L OO
HOUSE SEWER CONNECTING TO P C N
PRI gTE ISS S 1 CO IMP NO JO
WORK TO XOUIEIDEWER BLDG OR 1 00 TRUNK PERMIT NO OAD PERMIT YO
ATER REPAIR OR ABAN OON HOUSE $ID STATE ENCROACN YENT
ENDLlySTPERMIT NO
INDUSTRIAL
WASTE APP61"L'
CHAR
Owwms PEBMIi 2 00 CONNECTION CHARGE FEE
AUMOFMIION I TOTAL FEE c9 REIMBURSEMENT FEEI HAVE AT ^s r/J
TRACTOR TO THIS
THE ABOVE DESCRIBED EXISTING ADWELLING AMOVAM I DATE INSPECTOR SSIGNATURE
TO THE PUBLIC SEWER
SIGNED THIS DAY OF IQ NEW HOUSE SEWER
OWNER CONNECT ADDITIONAL JJ o
OWNERS AGENT BUILDING OR WORK /Z�B�
A
ADDRESS SEPTIC TANK SEEP PIT(S)
AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I 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 ALTER REPAIR SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT 1 AN PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT 1 AM THE LEGAL OWNER OF THIS ABOVE
DESCRIBEDRFAIDETIAL PROPERTY BACKFILL SE C TANKS
SIGNATURE SEEP PIT 9 CESSPOOLS
OF PERYI
ar VALIDATION ROBERT A WOOD
CL M.0. 2!! SUPERVIYINO MECHANICAL ENOINEM
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