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HomeMy Public PortalAbout4510 TEMPLE CITY BLVD_Sewer__ J Y iTo 76A 542D SAPPLICATION FOR PERMIT TEA COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL DEPARTMENT'OF COUNTY ENGINEER BUILDING AND SAFETY DIVISION BUILDING JOHN A LAMBIE COUNTY ENGINEER ADDRESS J C7 —e te- >, ✓y>' COLEMAN W JEN KINE SUP OF BUILDING LOCALITY TC nuwc$r 7(PRINT OR TLICAYPE ONLY)T YO L IN cwoq pT r�(//�L/�fI�Z✓�1 D[6CRIRIONNAILBLOCK /./ AODR[O JGI� no OF SLOGS61zC or LOTNow ON Lor CITY �[� TEL NO 7,USE OFBUILDING$ OIITRICT NO LROUP CLASP MAP PRGCEIDEO DY 6 K /P�p CONTRADTOR z ADDRESS .J) Zl' CONNECTION DATA CITY TEL NO STATIONA�Y_A;Z. DEPTH STATEl L ! MANHOLE REFERENCE I PP[R LICENSE NO OLAB6 _ No DESCRI ION OF WORK FEE TYPE OF CONNECTION NOT.FRON HOUSE SEWER CONNECTING TO Y CURB P L r L TOP L PUBLIC SEWER 0 t 00 p9PTC TANK [6[FAD[IIT OR JO NO FITS AND/OR DRAINFI ELO O $1000 CO IMP NO JOB NO NOU6E B[WHR CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO FRIVATCDIBPOpAL SYSTEM 0 Sam ' 'I / Q. CONNECT ADDITIONAL BLDG OR [AR FFIDAVIT BAIT�� 9MTIIfrT RECORD INETR NO DAT[ O WORK TO HOUGH SEWER O t300 u OVERFLOW SEEPAGE PIT ORAINFI[LD E[TN CESSPOOL ORYWELL MANHOLE C $60O ALTER OR D n Ow ABANDON HOUSE HWY OR ST WIDENING SEWER OR DISPOSAL SYSTEM $]OO STATE ENCROACHMENT PERMIT NO INDUSTRIAL a h {EE6f�p WABTL 6FFROVAIZ ovi7 E'S FERMft s CHARGES — AUTHOH>ZATION TOTAL PEE coNN[cTloN cHARG[rcc1 NAVE AT THIS DAT[ A CONTRACT WITH THE HEREIN NAMEDREIMBURSEMENT F[[ TRACTOR TOCONNECT THE ABOVE DESCRIBED [EIRINO DWEArinOVA�TO THE PUBLIC BEW[w DAT[ INSPECTOR 6 SIGNATURE SIGNED THIS DAY OP f OWN[w OR EW HOUR[6CW[ROWNERS AGENT ONNECT AOOITIONALADDRESS BUILDING OR WORK 1HEREBY ACKNOWLEDGE THAT 1 HAVE READ THI6 APPLICSEPTIC TANK $[[P PITIS) ANO STAT[ THAT THE ABOVE 16 CORRECT ANO AORC[ TO CANO/OR MAINFI[LO WITN ALL COUNTY ORDINANCES AND STATE LAWS R60ULFLU MBI NO AND 6EW ERS 4$POOL ❑ ORYW[LLIHEREBY CERTIFY THAT IAM PROPERLY REGISTERED ALTER REPAIR 6[W[ROR LICENSED A6 REDVFRED BY LOS ANGLES COUNTY AND STASEWAGE DISFOBAL SYSTEM CALIFORNIA OR THAT I AM L LEGAL OWNER OF AND INTEISCONNECT PLUGAMD RESIDE IN THE ABOV RI6 RESI [NTS L PROPERTYBANDON NOUS[S[WE" SIGNATUREAC KF ILL 6[P[IC TAXKS 1 OI IVALJACK R R ALLEN At 0 C r o CASH SUPERVISING MECHANICAL ENGINEER u u 1 5.0 0 Abs