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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 / G LOCALITY �j NEAREST FOR APPLICANT TO FILL IN CROSS ET L Gw 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 SK po 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 R}�� 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 7 445= 2Z10' Y 6.00e%