HomeMy Public PortalAbout5309 TEMPLE CITY BLVD_Sewer__ DEPAIITAUCNT OF 0OU24W ENa02;EER - ' SEWER—SEWAGE DISPOSAL 1
DIVISION OF BUnMING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANOELEB �^ Q BUILDING
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WILLIAM J FOX. COUNTY ENGINEER ADDRESS `J �D—/ /.0 yI��/� `Cl/ V
FOR APPLICANT TO FILL IN LOCALITY c G,
BUILDING YEAE6T
ADDRESS 6 / / PQM fl/ /M+ CROSS ST rj
LOCALITY L 016TRICT NO - SERIAL NO PERMIT NO
CR SST A _ 3 Aoc s
RECEIVED BY I fw Ioomtwo DATE ISSUED
OWNER PAZ .0ITS• c —A/-
NA1� USE ON6 OCCUPANCY MAP
ADDRESS A,
_ BK PB
CITY / TEL NO GOO'
CONTRACTOR T7 � ) 1 RAf;I I CO IMP MO 7
ADDRESS " V'7 LIR � Lti�( �}-U-P JOB NO
CITY G A4!��/E�L 11) Srtr-y6f TRUNK PERMIT NO
REGISTRATION NO / (� �/ �� ❑ COUNTY
�j r ROAD PERMIT NO
DESCRIPTION LOT NO �p �j o� STATE ENCROACHMENT
PERMIT YO
` BLOCK TRACT pI(S Sl d A! U I P � AC INDUSTRIAL '
✓ .�L WASTE APPROVAL
SIZE OF LOT X I��L•NOW ON LOO OF TS ,dty CHARGES
USE OF
BUILDINGS -P_g QSS I(IH� IE�-9'� COMNEC CHARGE FEE
NO. DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO REIMBURSEMEM
PUBLICSEWER • 0 800' RECEIPT NO ATE BY
HOUSE SEWER CONNECTINGTO . �
PRIVATE DISPOSAL SYSTEM - 100 _
C09NEC ADDITIONAL BLDG OR CEPTION REC D
WORK TO HOUSE SEWER - 100
ALTER OR REPAIR EXISTING NO DATE Y
SEWER OR DISPOSAL SYSTEM 100
DISCONNECT AND ABANDON SEWER
AND OR DISPOSAL SYSTEM 1 00 CONNECTION DATA
BE PT C7ANK SEEPAG PITON �+'
PITS AND/OR GRAINFIELD 700 STATION DEP"r'
EBSPOOLr UR WELL
SPECIAL CONDITIONS ONLY 700A./ �I ERENCE
/V O L ER
TYPE OF CONNE$10 METH FROM
OWNERS PERMIT : 00 Y CURB P L N L TO P L
AUTHORIZATION TOTAL FEE -
I HAVE THIS DATE CONTRACTED WIT" TN[ XEREIM NAMED 1
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INS PECTO6EIGNATUNE BATE
DWELLING TO THE PUBLIC SEWER _.
l
516NED THIS—DAY OF__'mie-_01 192- NEW x6u6E 6ewEq L7 t
OWNER OR ,/// CONNECT ADDITIONAL
OWNERS AG�ENN qT •T �^�rr�'''��_ _ BUILDING OR
WORK
AGGRESS J ]_-.4 - _ _ I� 1 AND/ORDPTIC RAIMFIELD IT(B)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI- CEPSPOOL[],ORWNELl.o -
CATION AND STATE THAT THE ABOVE HJTAgRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER REPAIR SEWF%OR „ari
REGULATING PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM,
I HEREBY CERTIFY THAT I AM PROPERLY RE EKED gCOMM[CT PLUG AMD
ANO/OR LICENSED AS REQUIRED BY LOS AMSEL UN -•-y- 2' -
AND STATE OF CALIFOfl OR THAT I THE B O SANDGM HOUSE SEWER
ER OF THE ABOVE D ED R ID P P BA F L AN
ATURE SEEP PIT(S)E'CES
OFSIGPEflNITIT
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