HomeMy Public PortalAbout4941 TEMPLE CITY BLVD_Sewer__ CEaoe ftGA84t"3APPLICATION FOR PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGMEEIi '
BUILDING AND SAFETY DIVISION BmLDINa t
IOHN A LAE® County EImp mmw ACI
WILLIAM A M10( I Sup t of BtddlBp [
LOCALITY
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FOR APPLICANT TO FILL IN °T
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DC1C"IPTION LOT NO y OWNER
/ MAIL
[LOCK TRACT / [J ADDRESS
NO OF SLOGS ,
SIZE OF LOT NOW ON LOT CITY TEL NO
UE[ OF
SUILOIMc• DISTRICT NO OROUR MAP PROCESSED DY
BK PO
C
ONTRACTOR
CONNECTION DATA
TEL NO d[ 3� 00 STATION DEPTH
STRATION NO 1 — I / COUNTYMANHOLE R[FERENC,pat
UDESCRIPTION OF WORK FE[ TYPE of CONNECTION L[ aTH FRow
HOUSE[EWER CONNECTING TO Y CURS P L ML TO P L Y
PUBLIC SEWER 0 55W O
SEPTIC YANK SEEPAGE PIT OR PC NO [�
PITS ANO/OR GRAINFIELD 0 /1000 CO IMP NO AOS HO v u
HOUSE[EWER CONNECTING TO TRUNK PERMIT NO gOAD PERMIT NO
p{
PRIVATE OItPOSAL SYSTEM 0 /300
C T ADDITIONAL SLOG OR AFFIDAVIT tA1Y0 [U[LI[IIT RECORD INSTR NO DAT[ `O
ORK OXOUon SEWER ALO 11300 3 g 1 •
OVE FLOW SEEPAGE PIT GRAINFIELD 1
EXTN CESSPOOL DRYWELL MANHOLE O 5500
ALTER RHWY OR 6T WIDENING Z
EPAIII OR^SAN DON HOUSE
SEWER OR DISPOSAL SYSTEM 0 113 00 STATE KNCnOACHM[NT z
PERMIT NO
INDUSTRIAL
WASTE APPROVAL
OTEN OLO3�L[1J PERMIT
[[ pEEf 2 00
AUTHORIZATION TOTAL FEE
CONNECTION CHARGE FEE
1 HAVE AT THIS DAT[ A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT PER
TRACTOR TO CONNECT THE ABOVE DESCRIBED EX13TIMO DWELLING APPROVALS
TO THE PUBLIC SEWER DATE INSPECTOR SIGNATURE
SIGNED THIS DAY OF 19_
OWNER OR NEW HOUSE SEWER
OW HERB ADEN T CONNECT ADDITIONAL 11
ADDRESS BUILDING OR WORK /y
i[PTICTANK SEEP PITI0I
1 HEREBY AT TH ABO THAT I HAVE READ AND
THIS APPLICATION AND/OR DRAINFIELD
AND STATE THAT THE DIVA IE LAND S AND AGREE E COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS I C[IEroOL ❑ DRYW 6LL ❑
1HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR S[W[R OR
LICENSED AS REOUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA 0R AT I AM THE LEGAL OWNER OF AND I"TCNO TO DSCORN[CT PLUG ANO
RCSID6 IN TH OVE GRIMED R[t1O TI^L PROPERTY ABANDON HOU{°°EWER
SIGNATURE OACKPILL SEPTIC TANKS
OF P[RMITTCQ SEEP PIT(S) LI Cbo❑OLE
ALIDATION ROBERT A WOOD
CK M O CASH SUPERVISING MECHANICAL ENGINEER
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