HomeMy Public PortalAbout5411 TEMPLE CITY BLVD_Sewer__ DEYAUTMENT OF COUNTY ENGINEER SEWER-SEWAGE DISPOSAL 1
DIVISION OF BUUMING AND SAFETY PERMIT APPLICATION
• COUNTY OF LOS ANOELES
WILLIAM J. FOX, COUNTY ADDRE
ENGINEER BUILDI SS NB ++ /
•
FOR APPLICANT TO RLL IN LOCALITY `p
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CONTRACTOR ��-N �JZJ��� CO•IYP NO �• —
ADDRESS
^ _ JOB NO
CITY I� ZhTE MOS TRUNK PERMIT MO �—
BTATE
REGISTRATION M ROAD PERMIT NO 3 '
LEGAL
DESCRIPTION LOT NO STATE ENCROACHMENT
PERMIT NO
BLOCK TRACT INDUSTRIAL
MOOW BLDG6 ^q q WASTE APPROVAL
SIZE OF LOT MOW F LOT ✓�' CHARGES
USE OF
BUILDINGS ReA/ CONNECTION CHARGE FE[`
MO DESCRIPTION OF WORK EE
HOUSE SEWER CONNECTING TO [ALTER
RSEMENT FEE
PUBLIC SEWER O 0 800 CEIPT NO DATE BY
HOUSE—SEVER CONNECTING TO
PRIVATE DISPOSAL SYSTEM 100
CONNECT ADDITIONAL BLDG R EXCEPTION RECORDED
WORK TO HOUSE SEWER 100
ALTER ER REPAIREXI8TING NO BATE BY
SEWER OR DISPOSAL SYSTEM 100
DISCONNECTAN ABANDON BEWEp
AMD OR DISPOSAL SYSTEM 100 CONNECTION DATA
SEPTIC TA PAG PIT OR /
PITS ANO/OR GRAINFIELD 200 N DEPTH
-cmPOOL—DRYWELL
SPECIAL CONDITIONS ONLY 200 1p^ MANHOLE REFERENC
O 4IAPER7 LOWER
E OF CONNECTION LENGTH F N
OWNERS PERMIT $ I 00 �R —tom M L TO P L
AUTHORIZATION TOTAL FEE �^
1 HAVE THIS DATE CONTRACTED WITH THE HEREIN NAMED
CONTRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING , PROVALS INSPECTOR'88 NATURE GATE
DWELLING TO THE PUBLIC SEWER
SIGNED THIS DAY OF 19_ OUSE SEWER
OWNERS OR
_ _ _ _ _ ___ MO ADDITIONAL
ADDRESS _ TANK SEEP PIT(S)
R DRA{NFIELD
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLI- OL E] DRYWELL❑
CATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE
TO COMPLY WITH ALL COUNTY ORDINANCES AND STATE LAWSREPAIR SEWER OR
REGULATING PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED
AND/OR LICENSED AS REQUIRED BY LOB ANGELES COUNTY DISCONNECT PLUG AND
AMD BTATH OFC RNIA OR THAA,T 1 AM THE LEGAL OWN- ABANDON HOUSE SEWER
ER OF THE ABOV D CRIB EBIDEMTIA PIIOPERTY KFILLB TANK
818 MATURE BEEP PIT(8I� CESSPOOLS E]
OF PERMITTEE _
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