HomeMy Public PortalAbout4353 TEMPLE CITY BLVD_Sewer__ TEMPLE CITY
'""'° APPLICATION FOR PERMIT
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COmNTT OF LOB "mm SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGnd=
BUUJMG AND BAFM DIVHION BUILDING 3
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BLOCK TRACT ADDRESS 1 F/NO OF 9LD
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SIZE OF LOT NOW ON LOTS I No. of
USE OF
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ADDRESS CONNE ON DATA
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SPATE MANHOLE REFERENCE UPPER
REGISTRATION NO COUNTY
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PUBLIC BEEWWEERECONNECTING TO ® S 00
SEPTIC T^^NK SEEPAGE PIT OH OF CONNE LENGTH FROM
PITS AND/OR DRAINFIELD SS 00 T CURB L ■L TO P L
OVERFLOW SEEPAGE PIT DRAINFIELD Q a
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W"NNTE DAAI pp TT CO IMP NO JOB NO
IC ttt10UffEI7ENIVAER LD1 OR 00 TRUNK PERMIT q0 ROAD PERMIT 0 ,
A T RED
R OR ABANDON HOUSE STATE ENCROACHMENT
Roll100 PERMIT NO
INDUSTRIAL
WASTE APPROVAL
CHARGES
OWNE" PERMIT 2 OO CONNECTION CHARGE FEE
AUMOBMTION I TOTAL FM REIMBURSEMENT FEE
I HAVE AT DATE A CONTRACT WITH THE TRACTOR TO CIONNECT THE ABOVE DESCRIBED QmISTINGAMED DWELLING AMOVAM DATE INSPECTOR!SIGNATURE
TO THE PUBLIC SEWER
SIGNED THIS-------DAY OF 19_ NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT BUILDING OR WORK
EPTIC ADDRF� AND/ORTANK DRAINFIELD (S)
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL DRTWELL
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEMOR
1 HEREBY CERTIFY THAT 1 AN PROPERLY REGISTERED AXD/OH DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I THE LEGAL OWN OF TXR ABOVE
DESCR18KD RESIDEN pxr BACKFILLS CTANK$
SIGNATURE C SEEP PITS CESSP00
OF PERMI
�F x e. ROBERT A WOOD
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GL L 4 CA0 SUPERVISING OB MECHANICAL IWOINIet
LACoo7752t APR g 1 o D 300 �!