HomeMy Public PortalAbout4331 1/2 TEMPLE CITY BLVD_Sewer__ APPLICATION FOR PERMIT 1
..f"•DMSION OF B=INa AND SAFETY SEWER—SEWAGE DISPOSAL
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M.J. FOX.CouNTY F%GINE[R
A
CArSATT D.GRIFFIN.SWT OF BUILDING LOCALITY
FOR APPLICANT TO FIM IN REARM
GAST.
DESCRIPT ON LOT NO. SaG f1lig R&OOWNER
BLOCK TRACT MAIL 1),QrAMAAlAlAlJyrA,. .9
ADDRESS
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SIII 0►Loi NON ON LOT AAoAe4S
CITY Agd, TEL.N0.
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BUILDINGS DISTRICT NO. GROUP YAP
CONTRACTOR r c I's
ADDRESS Q �7 CONIMCMIN DATA
CI7Y TEL.N0. STATION DEPTH I/
STAT[ MANHOLE REF[R¢NC[
REGISTRATION N0. 3 ;tkO COUNTY Kemp fll
TYPE OF CONNECTION L[NGTX FROr
No. DESCRIPTION OF WORK PER
CURB P
PUBLIC SEWER
CONNECTING To ® t 5.60 ~j \
HOUSE SEWER CONNECTING TO 7.
PRIVATE DISPOSAL SYSTEM 1.00 /
CONNECT ADDITIONAL BLDG. OR /] JOS. No.
�j 3
WORK TO HOUSE SEWER 1.00
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM I TRUNK PERMIT NO. ROAD PERMIT NO.
DISCONNECT AND ABANDON SEWER STATE ENCROACHMENT
AND/OR DISPOSAL SYSTEM 1.00 PERMIT NO.
SEPTIC TANK.SEEPAGE FIT OR INDUSTRIAL
PITS AMD OR DRAINFI¢LD !. INDUSTRIAL
ROYAL
CESSPOOL•DRYWELL
WASTE SPECIAL CONDITION ONLY ! CHARGES
CONNECTION CHARGE FE[
OWNER'S �mT s ao
AMORIZATION I TOTAL Tea Sl ry R[I1ISURSEYENT FES
I HAVE TKACTORTHIS DATETO CONNECCT
THE ABOVE IDESCR BEDY EII[STINGA DWELERIN NMED4M4 APPROVALS DAT¢ IMSP[CTOR'S SIGNATURE
TO THE PUBLIC SEWER
SIGNED THIS------DAY OF 19_ NEW HOUSE SEWER
OWNW 011 CONNECT ADDITIONAL
OW SR AGENT A� BUILDING OR NOR[
ADDRESS SNS RTDRAINFl6PLI1FI7lS)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CESSroOL❑ DRYNELLO
AND STATE THAT E TO COMPLY
WITH ALL YLL COUNTYORDINANCE ABOVE ES ANDS STAT[ LAWRRECT AND S REGULATINGOlt
FLUNKING AND SEWERS. SEWAGE
REPAIR.SEWER SYSTEM
I HEREBY CERTIFY THAT i AY PROPERLY REGISTERED AND/0R DISCONNECT
IS 0K ECTDISPLUS AND
LICENSED AS RlOUIR¢D BY LOS ANGELES COUNTY MD S7A OF ABANDON
N H FLOG AND
CALIFORNIA OR TYAT 1 Ar THe LE L ONN O 7R[ ABANDOII X Ub SEW[!
DESCRIBED RnIDKo LPltOPKRTY. BACKFILLC TANKS
SIGNATURE cl, 59" PIT I
OF PgYITT¢[
NTIWAM J.FOX.COumw mjsfN6m V ATION
or D 2 1 $ ria -111"J. 4 654[r9n
By BY
0 DEfUTT DEPUTY