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HomeMy Public PortalAbout4420 TEMPLE CITY BLVD_Sewer__ 21630 IMSEIM C9A088 AO 79Ae42o APPLICATION FOR PERMIT ' T MUM OF LOS ANGELPB SEWER—SEWAGE DISPOSAL 1 DEPARTMENT OF COUNTY ENGIN - - BUILDING AND SAFElY DMIXON ADDRESS UILDINBUILDING �Q cl I wai�L°AN�n t'a'Q+�a°es a3 �lamv LoceunEST FOR APPLICANT TO FILL IN CROSS SSTLEGAL Oct �jY c- DESCRIPTION LOT NO OWNER FO , /r A/Al BLOCK TRACT 'PAIL d P ADDRESS J OF BLOGS 812E OF LOT%Z NOW ON LOT CITY No USE �p DISTRICT NO GRO YAP ► KD BY BUI LDI N69 pa I CONTRACTORf (/ `O dt°�/ �rPK�QY � �— 9O ADDRESS .Z J� CONNECTION DATA CITY B rQTE L no G� --w STATION STATION DEPTH i T2 REGISTRATION NO I Z o pG 741 COUNTY MANHOLE REFERENCE V.T�� I PPER No 1� DESCRIPTION 0 WO FEE runggICSSEWERCONNECTINGTO S 00 pQ TYPE OF p LLNGTn FROM SEPTIC TANK SEEPAGE PIT OR f CURB P Y L TO P L PITS AND OR GRAINFIELD 0 sa GO OVERFLOW 9PeSSEPAGEp IT EGRAINFIELD SZ O HOUSE SEWER CONNECTING TO P C NO PRIVATE SI DO CO IMP NO JOB NO CONNECT�1UD9EISEWEBLDG OR TAUNK PERMIT NO ROAD PERMIT NO WORK TO IIOU $1.00 A TER REPAIR OR ABANDON HOUSE 1 STATE ENCROACHYEMT PERMIT NO a NDUSTRIAL WASTE APPROVA CHARGES OWNER'S PERMIS 2 00 CONNECTION CHARGE FES AUTHORIZATION TOTAL FEE - G� REIMBURSEMENT FEE NAMED COW TRACTOR TO CONNECTHAVE AT THETHE ABOVE DESCRIBED ES DATE A CONTRACT WITH THE DWELLING APPROVALS DATE INSPECTOR S SIGNATURE TO THE PUBLIC SEWER �l SIGNED THIS DAY OF 19_ NEW HOUSE SEWER OWNER OR / CONNECT ADDITIONAL / OWNERS AGENT BUILDING OR WORK +r ADORE / SEPTIC TANA SEEP PIT(S) AMD/OR GRAINFIELD 1 HEREBY ACKNOWLEDGE THAT I AVE READ LICATION - AND STATE THAT THE ABOVE IS CORRECT AND COMPLY CESSPOOL ORTWELL WITH ALL COUNTY ORDINANCES AND STATE ULATING PLUMBING AND SEWERS ALTER REPAIR 9L SYSEIHEREBY CERTIFY THAT I AN PROPERLY RAND/OR DESCONNEWAGE SPOSALTPLUG SYSTEM LICENSED AS REQUIRED BY LOS ANGELES COUNT TE OF DISCONNECT PLUG AND CALIFORNIA OR THAT I AY THE IEGAL OWNLABOVL ABANDON NOUSE SEWERDESCRIBED REBIOENTIALPROPERTYBACKFILL SEPT C TANKS (Y SIGNATURE SEEP PIT 9 CESSPDOLS 1 F PERMITTEEF 115 of /��ATION S SUPERVISING ME A WOOD ■ o TAaMECHANICAL KNIGINWI t e LCI o 1 5 2 8 zzl AUG 15 1 0 Q 500