HomeMy Public PortalAbout4800 TEMPLE CITY BLVD_Sewer__ TSA 6*2W- C;508 - 9/73 APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISION SUILDINO
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LOCALITY
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SIZE MOW ON LOT CITY TEL NO
USE
DISTRICT NO GROUP MAP OCE3810 BY
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LICENSE NO. TyABE �. MANHOLE P[F[RCMCC O /07 LO
WER
NO DISCRI"10 OF W RK I[[ TYPE Or CONNECTION LENGTH FROM !?
NOUS[III CONNECTING TO a Y CURS P Y L TO P l /`J
PUBLIC SEWER 0 fT 00
SEPTIC TANK PAGE PIT OR P C NO G
PITS AMD/OR DRAINFI[LD 0 f1000 CO IMP NO JOS NO a
HOUSE S!W[R CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO
PRIVATE DISPOSAL SYSTEM 0 Sf 00
CONNECT ADDITIONAL SLOG OR AFFIDAVIT SUTRf WERRn "CORD INS" NO DAT[
WORKTO H OUSCS[WER 0 53 ED
OVERFLOW SEEPAGE PIT GRAINFIELD Q
[KTN CESSPOOL DRYW[LL 0 55M HWY GREY WIDENING v
ALTER RVAIR O ABANDON HOUSE
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SEWER
OR DISPOSAL SYSTEM 0 $3 00 STAT[WCROACHMENT
MANHOLE 0 fT 00 PERMIT NO CWT
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OWNER'S PERM f cHARan
AUTHOFMTION TOTAL FEF 15- I CONNECTION CHARGE r[[
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT I[[r
TRACTOR TO CONNECT THE ABOVE DESCRIBED [LISTING DWELLING 1�AMOVAlQ
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TO THE PUBLIC SEWER DAT[ INSPV TOR S SIGNATURE
SIGNED THIS DAY OP IG_ O'
OWNER OR NEW HOUSE SEWER
OWNERS AGE NT
CONNECT ADDITIONAL
ADDRESS SU ILDING OR WORK
SEPTIC TANK BEEF PIT(Sl
I NM[SY ACKNOWLEDGE THAT I HAVE READ THIP'APPLICATION AMO/OR GRAINFIELD
ANO STAT[ THAT THE ABOVE IS CORRECT AND AOR99 TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ❑
PLUMBING AND S[W[RB CESSPOOL ❑ DRYWALL
1 HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AMO/OR ALTER "FAIR III
LICENSED AS R[OU IR[D BY LOS ANGLES COUNTY AND STAT[ OF SEWAGE DISPOSAL SYSTEM
CALIFDANIA OR THAT 1 AM THE LEGAL OWNER OF AND INTEND TO DI GCONMECT PLUG AND
RESIDE IN THE ABOVE DESCRIBED ID[NT L ROP ABANDON HOUS[BEWCR
SIGNATURE BACKFILL SEPTIC TANKS ❑
OF PEIMTTTC[ IEEr PITISI ❑ CESSPOOLS
IF VALIDATION K - M D CASH
9 8 7-DOCT 28 1 0 0- 1 5.0 0 ,&-*
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