HomeMy Public PortalAbout5249 TEMPLE CITY BLVD_Sewer__ I
DEPAIiThMNT OF OOUNTY ENODn= i SEWER-SEWAGE DISPOSAL
DIVISION OF sUMDING AND SAFETY - PERMIT APPLICATION
COUNTY OF LOS ANOELEB UILNO _
WILLIAM J. FOX, COUNTY ENGINEER I ADORESB -i-,Q.,,r�Q
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r CLOCALITrFOR APPLICANT TO FILL I
BUILDING �A / 7fl0888T< 4 / w`K1l p L l u
LOCALITY r DISTRICT NO SERIAL NO PERMIT NO c
NEAREST U A I� S
CROSS ST
OWNER lqo
RFCEIVEGer Re�dY for lnspoutlon DATEEIISSUED�
MAIL
ADORESS-20 3O lVi � HHUSE ZONE' OCCUPANCY Q` BK MAP pa
CITYLIS TEL NO
CONTRACTOR Q�V /. L/ CO IMP NO
ADDRESS 5- 'j a k, ✓/ JOB NO
CITEL NO TRUNK PERMIT NO
STAREGISTRATION NO � / 7 B COUNTYU .t
ROAD PERMIT NO
LEGAL S
DESCRIPTION LOT NO TATE ENCROACHMENT
PERMIT NO
BLOCK TRACT INDUSTRIAL
WASTE APPROVAL
SIZE OF LOT NO OF BLCHARGES
NOW ON LOT NO
USE OF
BUILDINGS CONNECTION CHARGE FEE
NO DESCRIPTION OF WORK FEE REIMBURSEMENT FEE
HOUSE SEWER CONNECT NG TO
PUBLIC SEWER ® i 760 RECEIPT NO DATE BY
UBE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 100
CONNECT ADDITIONAL BLI30 OR ,{,{ EXCEPTION RECORDED
WORK TO HOUSE SEWER 100 v V NO DATE BY
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM 100
DISCONNECT AND ABANDON SEWER
AMD/OR DISPOSAL SYSTEM 1 00 CONNECTION DATA
PTICTANK.SEEPAGE PIT OR
PITS AND/OR GRAINFIELD 200 L ✓� STATION DEPTH
OESSPO L—ORW LL
SPECIAL CONDITIONS ONLY 700 1 MANHOLE REFERENCE
UPPER LOWER
TYPE OF CONNECTION LENGTH FROM
OWNERS PERMIT $ DO Y CURB P L M LTO P L
_4 AUTHORIZATION TOTAL FEE —� _
1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR' IGNATURE DATE
DWELLING TO THE PUBLIC SEWER
SIGNED THIS DAY OF-----IV__ NEW HOUSE SEWER ' s
OWNER OR CO NNECT ADDITIONAL
OWNERS AGENT _ _ _ _ __ _ _ BUILDING OR WORK
ADDRESS __ - -- _ - T_ SEPTIC TANK.SEEP PIS)
AND/OR 0RAINFIE
I HEREBY ACKNOWLEDGE THAT I HAVE HEAD THIS APPLI CEBBPOOL ELL
CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER REPAIR SEWER OR
REGULATING PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED DISCONNECT PLUG AND
AMD/OR LICENSED AS REQUIRED BY LOS ANGELES COUNTY ABANDON HOUSE SEWER
AND STATE OF CALIFORNIA OR THAT 1 AM THE LEGAL OWN.
ER OF THE ABOVE DESCR ROPEBACKFILL SEPTIC TANK I]
SIGNATURE nry'/ I SEEP PIT(S)[] CESSPOOLS❑
OF PERMITTED[,+
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