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HomeMy Public PortalAbout5417 TEMPLE CITY BLVD_Sewer__ ° APPLICATION FOR PERMIT C140" �� COUNTY OF LOS ANGELES DEPABTe� OF COUNTY ENGINEERSEWER—SEWAGE DISPOSAL D BUILDING AND SAFETY DIMON ALDIxa DR649 CASSATS D. G88TIIP. Sup'1 of BRMiM LOCALTR 1 NEAREST FOR APPUCANT TO MI IN CROSS ST LEGAL DESCRIPTION LOT NO OWN[R BLOCK TRACT MAIL ADDRES NO OF SLOGS SIZE OF LOT NOW ON LOT TEL NO USE OF BUILDINGS k DISTRICT NO GROUP MAP PROCESSED BY ' sc Po CONTRACTOR 1 ADDRESS NNE ON TA CITY TEL No BTAnOfl Q d DQPTN t STATE REGISTRATION NO COUNTY MANHOLE REFERENCE No DESCRIPTION F FEE _ LOWER 00 IIIIREEUULIC SEWER SEWER CONNECTING TO ENS PIT�9 SND/OR DMI NF`HLD T OR S 00 TYPE OF CCURRBECTION P LENGTH FROM OVERFLOW IIL�EPAGE PIT DRAT NFIELp ' EXT CESSPOOL ORTWed MAN BOLE E 00 HOUSE SEWER CONNECTING TO P C NO PRIVATE DISPOSAL SYSTEM 1 00 CB IMP NO JOB NO NORRHTOT 10 7EIVERB lD6 OR 100 TRUNK PERMIT NO ROAD PERMIT NO AL REPAIR OR ABA N HOUSE STATE ENCROACHMENT 8 R OR DISP SA 8Y Y 1 00 PERMIT NO INDUSTRIAL W APR A CHARGES O�" FES Z Do CONNECTION CHARGE PER AUTHORIZATION TOTAL FEE BEIM9oRS li FEE I HAVE AT THIS OATH A CONTRACT WITH THE HEREIN NAMED CON APPROV DATE IN9PE R J IIIOMNBL TRACTOR TO CONNECT THE ABOVE DE9CB1 BTIN DWELLING TO THE PUBLIC JEAI SIGNED THtli�arr A OF xcw xousE SEWER OWNER OR CONNECT ADDITIONAL OWNERS AGENT BUILDING OR WORK SEPTIC TANK JQS Fly(s) ADDRESS AND/OR DMINFIQLb 1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CESSPOOL DRYWELL VTTII ALL COUNTY OROINANCEII AND STATE LAWM unfla ALTER REPAIR SEWER OR PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM 1 HEREBY CERTIFY THAT I AM STEREO AND/OR DISCONNECT PLUG AND LICENSED AS REQUIRED A ELKS OU AND STATE OF CALIFORNIA OR THAT THE OA Of OF TNR ABANDON HOUSE SEWER DESCRIBED RESIDENT ROPRHTT. BACIIFILT ffi C CANKJ❑ ,uL SIGNATURE �L.S OF PERRI 711 �P O� ROWOOD GMPM M.M. QUPeTMMWG NAlKCHMCNANIGAL MNOIT4MM9 X02 6 4 28; SEP 15 1 o A 5.00 N. 1