HomeMy Public PortalAbout4439 TEMPLE CITY BLVD_Sewer__ DEPARTMENT OF COUNTY ENGWIMM SMER--SEWAGE :DISPOSAL 1
DIVISION OF BUILDING AND 9A>;ETY HERMIT APPLICATION
COUNTY OF LOS AWGELES
WILLIAM J. FD?(, COUNTY ENGINEER `p BUILDING,II� /• ;
CABRATT 0. BRIPFIN SUPT OF BUILDING - I ADDRESS.
FOR APPLICANT TO FILL IN LOCALITY /) .
BUILDING- �J NEAREST. I .,
ADDRESS 1{�/p 9 I &M �C 7V 1.7� GROSS ST.'
LOCALITY QS-C, 4T Dib=RIETINO A.I�'.S�E"IAL N0: q.,fERM1)T NO. S
NEAREST - '. 1 rl = �1 a. J3
CROS SST.�bW I `Y. /Q'.' t�rn �.,IR (� RECEIVED BY Reedg for Inspection DATE ISSUED.
OWNER �/'I� l '
MAIL USEZONE OCCUPANCY MAP.
A Db RESB .: BK PB.-
CITY
CONTRA O CHARGES REIIIIBDRSEMENT FEE J
ADDRESS REQUIRE
1 ? _ REQUIRED
�/ NOT REOU
CITY -.i TEL.NO.rOr• � '�. 'dOBM CONN N C N1RRE FEE - -
�' STATE -: CO.IMP. N0. 1
*REGISTRATION,LEGALNO. COUNTY 6 TAJ RECEIPT NO. ` DATE - `BY
DESCRIPTION. ', LOT N0. I l
BLOCK zTRACT.-# WAIVER FOR-RECOlDtN6-"__ '
IZE OF LOTd ROW UR ljpLDTS. RECEIPT NO." DATE BY .J
USE OF ^i
BUILDINGS TRUNK PERMIT N0.
y+ NO. DESCRIPT40N OF WORK FEE
HOUSE SEW R CONNECTING TO ROAD PERMIT NO..
PUBLICSEWER -'!.S 5:50 I _
NO USE SEWER-CONNECTING TO STATE ENCROACHMENT' _
PRIVATE DIS_ L SYSTEM 1.00 PERMIT NO. - �?
CONNECT A ONAL9BLOG.OR INDU1IGTRIAL
O HOUSE SEWER '
WORK TOO 1.00 WASTE APPROVAL
ALTER OR NEPAIREXISTING
SEWER OR DISPOSAL SYSTEM I.W CONNECTION DATA
DISCONOSALSYSTEM IAO
66IIECT AND ABANDON SEW STATION.) 1 3 - D PTH
DISC
OM '
SEP iC TEEPAGE PIT OR - J.�- II,,
PITS.AND/OR DRAT FIELD - i2ld I..> - MANHOLE REFER NCis? LOW R
CESSPOOL—DRYWELL ``
SPECIAL CONDITIONS ONLY X200 1T-%t _I_ .
TYPEOF CONNECT10 LENGTH FRO
dL_ CURBIS HIOL.
OWNERS ' PERMIT s :11 00 —
AUTHORIZATION ' TOfFAL FEE !4 liz
I HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING - APPROVALS INS, ECTOR'S SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER
.� -NEW HOUSE SEWER I ` L "r
SIGNED THIS...... . . .D OF._.........— ,__: - ---
OWNER OR _ LYN _ BUILDING ADDITIONAL
B WORK
Ts y �` N
WNERS AGER _
/ ( - --� ---- n SEPTIC TANK,SEEP.PIT(S)
ADDRESS------ AND/0 ,DRAINFIELD e
1 HEREBY ACKNOW LEyLV_E TN 'eE` .av�...a DRYWELL El
CATION AND STATE THAT-T
TO COMPLY WITH ALL COU - T AL AIR BEW.ER�EM r
REGULATING PLUMBING AN Ba - -
1 HEREBY CERTIFY THAT P' IN -r
AND/OR LICENSED AS REQUIRED BY'LOS •NELEB _
AND STATE OF CALIFORNIA OR TIMI AT 1 M T
ER OF THE ABOVE DESWBED RESIDENTIAL
SIGNATURE
OF PERM ITTE As•(:..K/rfy�^.y'S 'r
76A642D 663`12/92 -
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