HomeMy Public PortalAbout4430 TEMPLE CITY BLVD_Sewer__ ,
D BoraE as '•
7BA64M APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL IJ
DEPARTMENT OF COUNTY ENGINEER ,o
BUILDING AND SAFETY DIVISION RU LD'No 3 O T.Mf�C C..?Y 4.Y
.�O•}•D-I•-A LAMHfE Ce>®7 ED�IO{x ADOR[SS
WMA IENSSl1 SpP` f H GW{L I g LocALm L (�/
M[AR[{T
FOR APPLICANT TO FILL IN CROBe BT
L AL
DESCRIPTION LOT NO OWNER
MAIL BLOCK TRACT ADORIf{ HPLf�)FEL NOCITYUSE or
BUIILDNG, 'CAENc D18TRICT NO ORO���III MAR PROrte) RCKPOV `ADDRESS /j- CONNECTION DATA
TEL NO —ISTATION DEPTHTATE REGISTRATION NO COUNTY MANHOLE R[F[REXC!
NO DESCRIPTION OF WORK FEE TYPE OF CONNECTION LENGTH FROM
HOUSE{EWER CONNECTING TO Y CURB F L M L TO P L
PUBLIC SEWER O {500
SEPTIC TANK SEEPAGE PIT OR J C NO U
FITS ANO/OR ORA INFIELD Y SIO OO CO IMP NO JOS NO
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO
PRIVATE DISPOSAL SYSTEM Q $300
CONNECT ADDITIONAL AFFIDAVIT SMT., ......Rl RECORD INSTR NO DATE
WORK TO HOUSE SEWER O 6300
OVERFLOW SEEPAGE PR DRAINPIELD
EATH C[WPOOL DRYWELL MA N HOLE C S500
ALTER REPAIR OR ABANDON HOUSE HWY OR ST WIDENING
SEWER OR DISPOSAL SYSTEM B 53 00 STATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
[ P OVA
��POE,TWNER' p s z o0
AUTHO ON T ALFELY �1 COMNE ION CHAR FE!
I HAVE AT TH18 DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FE!
TRACTOR To CONNECT THE ABOVE DESCRIBED E%IBTIXO k LLLINO APPROVALS
TO THE PUBLIC SEWER DATE INSPECTOR B GIGNATUR[
SIGNED THIS DAY OF IG_
OWNER OR NEW HOUSE SEWER
OW NERS AGENT CONNECT ADDITIONAL
ADDRESS SU ILDINO OR WORK
I HERESY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION SEPTIC TANK {[IE PIT(S)
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY AND�OR GRAINFIELD
WITH ALL COUNTY ORDINANCE6 AND STAT[ LAW{ REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWELL ❑
1 HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF G[WAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT 1 AM THE L[OAL OWNER OF AND INTEND TO OIGCONX[CT PLUG AND
ReelDe IM THE ABO/VE D[SLR/IJB[O RISI/D.�[MTIAO PROPE/I AISCONN MOUSE SEWER
AND
81OF PER �� (( P,/jF _ i�J� SACKFILLSEPTIC TANKS
OF
P[fl WTTEG /LQAiLA' C Ll l�/4C/[+� �C/ BEEP PIT(G) ❑ CESSPOOLS
VALIDATION ROBERT A WOOD
CK M D CA{H - SUPERVISING MECHANICAL ENGINEER
LACO3 1 s 8t2 APR 11 1 0 D 5.00-
`�� -17