HomeMy Public PortalAbout4304 TEMPLE CITY BLVD_Sewer__ CEBOB' °' APPLICATION FOR PERMI/
TBAe+so COUNTY OF LOS ANGELES
DEPAHTMENT OF COUNTY ENGINEER SEWE —SEWAGEDI.P.SA
BUILDING AND SAFETY DIVISION eu1LolNa w'a,
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FOR APPLICANT TO FILL. INLEGAL
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DESCRIPTION LOT NO QCT OWNERfAl /46A V Nod
BLOCK TRACTMAIL
5 ds ADDREe! 0O / "Alf .G � ♦ '
NO OF SLOGS
SIZE OF LOT NOW ON LOT CITY TEL NO
USE OF DISTRICT NO GROUPMAP I OCC6 LY
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CONTRACTOR G O.e S O• 50� eK PO�
ADDRESS �!/ r0.¢A/ETr CONNECTION DATA
CITY EL TEL No ,— O ION S
DEPTH
TATE MANHOLE`! ALN [
REGISTRATION NO COUNTY OWER
No DESCRIPTION OF ORK FEL TYPE o NN CTION L[N IT FROM /
HOUSE SEWER CONNECTING TO Y CURB P L M L TP
L
PURLICSEW[R O EBoo PC MO
SEPTIC TANK SEEPAGE PIT ON I JOB NO
PITS AND/OR DRA INFIELD d uoGo CO IMP NO ���///
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO f / C
PRIVATE DISPOSAL SYSTEM Y Ei 00
CONNECT ADDITIONAL SLOB OR AFFIDAVIT WAIVER T 909NT RECORD INS" NO GATE
WORK TO HOUSE SEWER C S..
OVERFLOW SEEPAGE PIT GRAINFIELD
ELTN CES/POOL ORYWELL MANHOLE O 15M
ALTER REPAIR OR ABANDON OUSE HWY OR 6T WIDENING
SEWER OR DISPOSAL SYSTEM C SSQO STATE ENCROACHMENT
PERMIT NO
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(INDUSTRIA
PP
CHARDS/
OWNER'S I P s 9 DD
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN N ED CON REIMBURSEMENT FELE}p
S
TRACTOR To CONNECT THE ABOVE DESCRIBED EXISTING OW[LLINO APPROVAL
TO THE PUBLIC SEWER DATE INSP O SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER •.2
OWNERS AGE HT
CONNECT ADDITIONAL
ADOR[SS BUILDING OR WORN
I HERESY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION SEPTIC TANK S[EP PIT(S)
AND/OR IXiAINFI[LD
AND STATE THAT THE ABOVE IS CORRECT ANO AOR[C TO COMILV
WITH ALL COUNTY ORDINANCES AND STAT[ LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
I HENS°Y CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR /EWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE LEGAL OWNER 01 AND INTEND TO DISCONNECT PLUG AND
RESIDE IN THE A V[ DGLRI/ED RESIDENTIAL PRONE ABANDON HOUSE SEWER
SION TURE
PKRM
01 PERMITTEE �7 BACRIILL SEPTIC TANKS El
/ESP nr(S) ❑ c[/wools
IF If VALIDATION ROBERT A WOOD
" CR y O CASH SUPERVISING MECHANICAL ENGINEER
,05 b 94� FEB 19 1 0 D 7.0 t7
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