HomeMy Public PortalAbout5015 TEMPLE CITY BLVD_Sewer__ 70A842 °-0'
0APPLICATION FORj PERMIT
COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
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BUILDING AND SAFETY DIVISION eu aDlNa � Ci� -��✓�
IOFffi A LAMBLE, County EDy ,N A
IODREEe 36
WILLIAM A umm, Supt DI Building ��' C•7 �y
LocALITY i /ttr
FOR APPLICANT/TO EM IN
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DESCRIPTION LOT NO�'�(p/J OWNER /f/Q� /��(�✓Q� /'
MAIL
{LOCK TRACT ��/��[. ADDREas /P/�GQ �j r
NO OF [LOOS
SIZE OF LOT NOW ON LOT CITY C L NO
UB¢ OF 01ST*ICT NO GROUP MAP CSS¢D BY
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CONTRACTOR
ADDRESS/30J�- �CivG dnO.�/46-`Qre✓G /J CO 'TION DATA
CITY 11114W/fPG1G TML NOT�6��7�.>T STATION O[PTH
REGISTRATION NO 6, 047 A�X02 STATE MANHOLE REFERENCE UPPER
CounTY .UPPER
NO DESCRIPTION OF WORK FCS TYPE OF CONNECTION LENGTH FROM
OUSE SEWER CONNECTING TO ` Y CURB P L M L .PL
PUBLIC{EWER tS 00 `/ oty ZL
SEPTICTAMK SEEPAGE PIT OR PC NO 2 2 Q O
PITC AND/OR DRAINFIELD [1000 CO IMP NO JOS NO o V
HOUSE SEWER CONNECTING TO THUNK PERMIT NO ROAD PERMIT NO ME
PRIVATE DISPOSAL SYSTEM 0 iS 00
CONNECT ADDITIONAL BLVD R AFFIDAVIT O
R4v[A flvvRVXT RECORD INSTR NO OATS 0
WORK TO HOUSE SCW[R O tS W
OVERFLOW SEEPAGE PIT GRAINFIELD 6
[XTN CESSFOOLDRYWELLMANHOLZO SS00 NWY OR ST WIDENING y
ALTER REPAIR OR ABANDON HOUSE Z
{EWER OR DISPOSAL SYSTEM O O00 {TATE ENCROACHMENT
PERMIT NO
INDUSTRIAL
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�Ti p WAST[APPROVAL
OWNERTS PERNNT f 2 00 CHARGE*
AUTHORIZATION TOTAL FEE QO CONNECTION LNAROH FEE
1 HAVE AT THIS DAT[ A CONTRACT WITH THE H[R[IN NANCO CON NEI MSURSEMEW FEE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING wmmRO`.
TO THE PUBLIC SEWER IPC • DAT 1 CCTORSSIONATURL
SIGNED THIS DAY O�P/ 19_ /
OWNER OR ✓e NEW HOUSE SEWER
OWNERS AGENT CONNECT ADDITIONAL
ADDRESS BUILDING OR WORK
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION SEPTIC TANK SCEP PITT{)
ANO BTATC THAT THE ABOVE IS CORRECT AND AORIE TO COMPLY ANO/OR GRAINFIELD
WITH ALL COUNTY ORDINANCES AND {TATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ DRYWLLL ❑
1 HEREBY CERTIFY THAT 1 AN PROPERLY *MOISTENED AND/OR ALTER REPAIR SEWER OR
LICENSED AS R[OU IR[ BY LOB ANGLES COUNTY AN0 STAT[ OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT A TH[ L[OAL OWNER OF AND INTWO TO DISCONNECT PLUG AND
RESIDE IN THE AS C CRIS[p R 1 ROPERTY ABANDON HOUSE SEWER
SIGNATURE MCKFILL B[PTIC TANKS ❑
OF P[RMITTM[ BEEP PIT(*) ❑ CESSPOOLS
VALIDATION ROBERT A WOOD
cR M o CASH SUPERVISING MECHANICAL ENGINEER
LAC06 0 3 9Z9 FEB 28 1 0 ® 7.00~ a