HomeMy Public PortalAbout5404 TEMPLE CITY BLVD_Sewer__ DEPASTMENT OF COUN'J(Y EN(iea= SEWER-SEWAGE DISPOSAL 1
DIVISION OF BUILDING AND SAFETY PERMIT APPLICATION
COUNTY OF LOS ANGELESBUILDING
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WILLIAM J. FOX, COUNTY ENGINEER ADDRESS 5 -1i9 ,(I T FP (/�/i and
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, - Z 'f�,fr��7� RECEIVED BY Body for la.r.nwn DATEIBBUEO
H�O GSISEZONE OCCUPANCY BK MAPpeA00RE68 r/
CITYj>ja� LJ„�y TEL NO
CONTRACTOR A r/ CO.INP NO - 8
ADDRESS t 0 / I 2r 5 (''II L JOB.NO
CITY TEL NO rja K �n TRUNK PERMIT NO
REGISTRATION NO p -3 COUMTY ROAD PERMIT NO
LEGAL
DESCRIPTION LOT NO g� STATE ENCROACHMENT
PERMIT NO
BLOCK TRACT �C%bd INDUSTRIAL �r
�!1 WASTEAPPROVAL
SIZE OF LOT/,5-&X �J7�JNOW ON LOTS CHARGES
BUILDINGS DUSEOr CONNECTION CHARGE FEE
BUILDINGS Q_ T
NO DEBCRI N IDOF WORK FEE REIMBURSEMENT FEE
H US WERC IIB TO
PUBLI08EWER @ OMI 3 JRECEIPT NO DATE BY
NOOSE SEWER CONNECTING TO �-
PRIVATE DISPOSAL SYSTEM 100
COMNECT ADDITIORAL BLDG OR EXCEPTION RECORDED
WORK TO HOUSE SEWER 100 O DATE BY
ALTER OR REPAIR EXISTING
SEWER OR DISPOSAL SYSTEM 100 -2—
DISCONNECT AND ABANDON SEWER
AMD OR DISPOSALSYSTEM 100 CONNECTION DATA
SEPTIC TANK SEEPAGE PIT OR
PITSAND OR 0RAINFI ELD 2d0 STATION -7 STATION DEPTH
CESSPOOL-ORYWELL
SPECIAL CONDITIONS ONLY 200 MANHOLE R[FC
UPPER ! I Of-
LOWER
Y TYPE OFC CONNECTIRB ON L LENT
L TO FROM /S/
OWNERS PERMIT s I DO
ALITHORIZATION I TOTAL FEE IV m
1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING APPROVALS INSPECTOR'S SIGNATURE DATE
DWELLING TO THE PUBLIC SEWER
SIGNED THIS�/ DAY OF I 19 NEW HOUSE SEWER
CORRECT ADDITIONAL
OWNER OR BUILDINGORWORK
OWNERS AOEMT` SEPTICTANK BEEP PIT(S)
ADDRESS _ N6 ANO/OR GRAINFIELD
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS AP LI CESSPOOL[] DRYWELL
CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWS ALTER REPAIpp,,SEW ER OR
REGULATING PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
AMD%OR LICEEREBY NSED IAB THAT
AN PROPERLY
ANGELESSICOUNTY DISCONNECT PLUG AND
AMD STATE OF CALIFORNIA OR THAT i AM THE LEGAL OWN. ABANDON HOUSE SEWER �1
ER OF THE ABOVE DESCRIBED RE81A� PROS PERTY IC TANK5
SEE PIT(8)OTCESSPOOLV ` -13
SIGNATURE L'///J/sL�I�V^__,..-
OF PERMITTEE
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