HomeMy Public PortalAbout5417 TEMPLE CITY BLVD_Sewer__ ° APPLICATION FOR PERMIT
C140" �� COUNTY OF LOS ANGELES
DEPABTe� OF COUNTY ENGINEERSEWER—SEWAGE DISPOSAL
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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.
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