HomeMy Public PortalAbout4367 TEMPLE CITY BLVD_Sewer__ JY
75A BA2D -CES OR-10-71 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION BUILDING
ADDRESS
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LOCALITY �j
NEAREST
FOR APPLICANT TO FILL IN CROSS ET
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DESCRIPTION IDT NO O OWNER 1
MAIL
BLOCK TRACT ADDRESS
NO OF BLDG•
SIZE Of LOT NOW ON LOT I CITY (�/ TEL NO
USE OP
BUILDINGS DISTRICT NO GROUP MAP CESSID BY
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CONTRACTOR DLCO C G (J 7®
ADD"— co CTTON DATA
CITY TEL NO �.S STATION /..�. � DCPYM
STATE LIC MANHOLE R EFLRINCL UP R
LI CENSE NO CLASS LOWIfl
NO DESCRIPTION OF WORK PER TYPE OF CONn[cTlo LENGTH FROM
HOUSE SEWER CONNECTING TO Y CURB M L TOP L
PUBLIC SCWCR O $T 00
SEPTIC IANR S[fPAGC PIT OR P.C.
C NO
PITT AND/OR DRAINIIILD Y SID OO CO IMP NO OS XO
H OUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO D.
PRIVATE DISPOSAL SYSTEM Y $300 O
CONNECT ADDITIONAL BLDG OR AFFIDAVIT DAT[ (�
WORK TO HOUSE SEWER 0 SSW
OVERFLOW SCCPA OE PIT DRAINFl[L. O
N CLSSPOOLG.YWELL Y SS GO HWY ORST WIDENING I...
ALTER REPAIR OR ABANDON HOUSE ^D
SEWER OR DISPOSAL SYSTEM C SSW
I/ STATE ENCROACHMENT
MANHOLE 0 $T 00 PERMIT NO y
INDUSTRIAL y
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WASTE APPROVAL
OWNER'S I PERM $ 31 00 CHARGES
ADTHOBMnON I TOTAL FEE 6) CONNECTION CHARGE FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLINO
TO THE PC p AP!<80VATS
UBLI //JJ DATE INSPECTOR a SIGNATURE
SIGNED THIS AY/6 F '0.-y _IG
OWNER OF ,%p3yG�/lam/-J=.��Y� NEW HOUSE SEWER
OW NER9 AGENT CONNECT ADDITIONAL
J �_. - ���
ADDRESS e A BUILDING OR WORK
SND/ORKPTIC ANKDRA BEEP PIT(6)
HEREBY THAT
TH ABO THAT 1 HAVE RIND THIS ATO COMPLY AND/OR GRAINFIELD
WITH STATE THAT THL ABOVE le CORRECT AND ACRE[ E COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ❑
FLU MIS
AND SEWERS CESSPOOL ❑ pRYWILL
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THF,LCO L OWNER OF AND INTEND TO DISCONNECT PLUG AND
RESIDE IN THE ABOVE C BE [SIpINTIA PERTY ABANDON HOUSE SEWER
SIGNATURE
OF PERMITTEE SACKFILL SEPTIC TANKS ❑
�T�IS SCEP PIT(S) SPOOLS
VALWATION CK M 0 CASH
7
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