HomeMy Public PortalAbout5330 TEMPLE CITY BLVD_Sewer__ APPLICATION FOR PERMIT f
COUNTY OF LOS ANGELES SEWER.—SEWAGE DISPOSAL 1
DEPARTMENT OF C40UNTY ENGDNEER
BUM)ING AND SAFETY DIVISION eulAD Loa�iso 3 IC L8 /v ,
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ESCRIPTION LOT n0 NxEa
TRACT EAI"ADDRESSNO OF BLDGS
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NGS 1� DISTRIRNOGROUP YAPCTOB (/{` � °� KS / c�/ CONNNE=ON DATA
7E TEL NO �p STATION d DEPTH
RATIOX NO �J arATE MANtlOLE aEPER®ICR i/D SCRIPTI F WOR FEEOUSE SEMER CONNECTING TO
PPU BLIC 9ENER S00 TYPE OF CONRECTIO LENGTH FAOY O
EPTIC T/�NR SEEPAGE PIT OR T CUP LMLTOPLITO AXD/ORDRAINFIELO !00
VERFLOW SEEPAGEPT DRAINFIbL0EXTN CES! L DRTNELL MANHOLE Y 00HOUSE HEWER CONNECTING TO P C NO
PRIVATE DISPOSAL SYLSTE■ 1 00 0 IMP NO JOB NOzp./�O�77R[[IKC TOpp HOUSE SEWERSLpDpG OR 1 00 TRUNK PERMIT NO ROAD PERMIT NO 16 p7�G95 OR DISPOR OSAL 374Tfi IS NOOSE 1 00 STATE[KYR ENCROACHMENT
INDUSTRIAL
WAST APPROYA
CHARGES
OWNER'S PETWT 00 CONNECTION CHARGE FEE
AUMOIMTION TOTAL FEE p0 REIMBURSEMENT FEE
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON APPHOVAIS DATE INSPECTOR S SIGNATURE
TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEN6a
SIGNED THI / v AY OF 19v— NEW HOUSE SEWER
OWNER OR CONNECT ADDITIONAL
OWNERS AGENT -BUILDING OR WORK
ANKEp
ADORNEI
AND/ORTDRAI LO PITS)
1 HEREBY ACKNOWLEDGE THAT NAVE READ IS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL 13 DRYWELL
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER REPAIR SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
I TH
HEREBY RT AT I AN PROMMLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSEDus IRED BY LOS ANGELES COUNTY AND n OF ABANDON HOUSE S
B IDK IAL P EWER
CALIFOR A OR T T I T OW ,% VE
DESCRIBACKFILL SEPBC TANKS❑
SIOHATURE .. SEEP PIT(S) CFSSP00V
OF PERYI
Or VALIDATION ROBERTA WOOD
u ■ a CYE YUPERVIYINa NRCHANICAL RNa1NERR
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