Loading...
HomeMy Public PortalAbout5424 TEMPLE CITY BLVD_Sewer__ af �:fe ID-e0 TSAa4eAe�xD APPLICATION FOR PERMIT COUNTY OF LOS ANGELES SEWER-SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DMSION ADDRESS `5�..¢ ;a 771& C c+ Wm A L11NB1E County Enrq1n— ADDR[as WILLIAM A. IENSEN SUP 1 o/ 6u,,dmp LOCALITY /C�/J�J I.P.. �✓� NEAREST FOR APPLICANT TO FILL IN CRo00 BT LEGAL O[SCRIIPTION LOTND OWNER 1 \ MAIL BLOCK TRACT ADDRESS Ll NO OF BLDOa 1 SIZE OF LOT NOW ON LOT CITY TEL NO BUILDINGS DI �`���� DISTfl ICT NO GROUP MAP PROCESSED BY USE OIHOB SK PO CONTRACTOR�j.Q.dor/fom �O 'B ADDRESS /,3p '�i►'e �iG p✓o CONNECTION DATA CITY TEL ��'�`�- STATION /'� DEPTH / G 3 C�� �'\� MANHOLE REFERENCE UPPER REGISTRATION NO COUNTY LOWER NO DESCRIPTION OF WORK FEE TYPE OP CONNECTION L THPROM HOUSE SEWER CONNECTING TO Y CURS PL M L T a PUBLIC SEWER O [S OO SEPTIC TAXK 8 PAGE PIT OR PC NO PITS AND/OR GRAINFIELD Y LI000 CO IMP NO JOB No O HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO PRIVATE DISPOSAL SYSTEM C SS 00 0 CONNECT ADDITIONAL BLDG OR AFFIDAVIT [Y[R[IIi RECORD INS" NO DAT[ O` WORKTO HOUS[SEWLR Y [i00 1 • OVERFLOW SEEPAGE PIT DMAINFlLLD [VY KXTR CESSPOOL DRYW[LL MANHOLE Q BS 00 d ALTER R HWY OR ST WID NINO Q $3 GO STATE ENCROACHMENT PERMIT NO INDUSTRIAL WAR[APPROVAL c oc0 }�PO�WNERS PERMIT s z 00 AUTHORIZATION TOTAL FEE 00 CONNECTION CHARGE FEE 1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE TRACTOR TO CORRECT THE ABOVE DESCRIBED EBISTIMO DWELLING w� OV DATE INSPECTOR 9H10XATURL TO THE PUBLIC SEWER AC SIGNED THIS DAY OF Ie_ OWNER OR NLW HOUSE SEWER OW ME ME AGE MT CONNECT ADDITIONAL ADOM[SB BUILDING OR WORK SEPTIC TANK SEEP PIT(S) I HEREBY ACKNOWLEDGE THAT I HAVE READ L ICATION ANO/OR DIIAINFICLD AND STATE THAT THE ABOVE IS CORRECT AND OMPLYWITHALL COUNTY ORDINANCES AND RATE LATING PLUMBING AND SEWERS CESSPOOL ❑ DRYWCLL ❑ 1HEREBYCERTIFY THAT I AM PROPERLY REND/OR ALTER REPAIRSEWER OR LI[ENSED AS REQUIRED BY LOSANGLES COUNATE OF SEWAO EDISPOSAL SYSTEM CALI ROMMIA OR THAT I THC LIOAL OWNER OEND TO DISCONNECT PLUG AND RESIDE IN THE ABOV HIRED ME DENTIAL ABANDON HOUSE SEWER SIGNATURE OF PPERMITTERM EE BACKFILL SEPTIC TANKS ❑ BIEP PIT(S) ❑ CISSPOOLS AMATION ROBERT A WOOD CK M D CASH SUPERVISING MECHANICAL ENGINEER _ [j�7 a 0 5Q [uw22 1 0 � 5.00- + t�� - _ ..