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HomeMy Public PortalAbout5430 TEMPLE CITY BLVD_Sewer__ CE808 CEGB )o-Bi"( D APPLICATION FOR PERMIT COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DMSION D ING 3 O 10 7 A LAbOM Cc t, >rqm.. ADD' WILLIAM A. JENS$7 SGP 1 GI eMddup �o LITY EST FOR APPLICANT TO LINEfNEAE ST E➢C ION LOT NO pLOCN TR ` ADDS e HO OF BLDO8 SIZE OF L MOW ON LOT CITY TEL NO BE OF S DISTRICT NO OROUF MAP F C[pZED BY OUILDINOO RK FO CONTRACT �� �a � .9 ADDRESS /� V ^CONNECTION CITY STATION y DEPTH REGISTRATION NOe4ed 6 COUNSTATE MANHOLEFERENCE RE14PS�I LOWER NO DESCRIPTION OF WORK F[S P[OF CONNECTION LENGTH FROM HOUSE SEWER CONNECTING TO CURB PL ML TO P L Y PUBLIC SEWER Y [BOp ' d SEPTIC TANK SEEPAGE FIT OR PC NO O PITS ANO/OR DRAINFIELD {IO GO CO IMP NO JOB NO v HOUSE SEWER CONNECTING TO PRIVATE DISPOSAL SYSTEM G {S as TRUNK PERMIT NO ROAD PERMIT NO "-ArE K COMN[CT ADDITIONAL BLDG OR AFFIDAVIT [4Y(( (1((R(Rl RECORD IN IR NOO WORK TO HOU{[SEWER m {]GG OVERFLOW SEEPAGE PIT DRAINFIELD 6 E%TN CESSPOOL DRYW[LL MANHOLE O $5 DO HWY OR QT WIDENING ALTER REPAIR OR ABANDON MOUSE 441Z SEWER OR DISPOSAL SYSTEM {i M STATE ENCROACHMENT PERMIT NO INDUSTRIAL WASTE APPROVAL OWNER'S PERNiR' s z 00 CHARGES AUTHORIZATION TOTAL FEE L/I CONNECTION CHARGE FEE 1 HAVE-AT THIS DATE A CONTRACT WITH THE H[REIM NAM[O CON REIMBURSEMENT FEE TRACTOR TO CONNECT THE ABOVE DESCR CD [RISTIMG DW[LLIMO APPROVAL) TO THE PUBLIC S[W fl DATE I SPECTOR S WOMATUR[ SIGNED THIS _DAV OF t OWNER OR NEW HOUSE SEWER 3 OW M[RS A6CNT CONNECT ADDITIONAL e LPESIDE S BUILDING OR WORK U BEPTC TANK SEEP PIT(S) EBY ACKNOWLEDGE THAT HAVE RSAO THIS APPLICATION AND/OR GRAINFIELD TE THAT THE ABOVE 16 CORRECT AND AOR[E TO COMPLY LL COUNTY ORDINANCES AND STATE LAWS REGULATING G AND SEWERS CESSPOOL ❑ DRYW[LL ❑ EBY CERTIFY THAT I AM PROPERLY REGISTERED AMD/OR ALTER REPAIR SEWER OR D AB REOUIRED BY LOS ANGLES COUNTY AND STATE OF "WAGE DISPOSAL SYSTEM NIA OR THAT I AM THE LEGAL OWNER OF AND I ND TO pISCOMN[CT PLUG AND IN THE ABOVEDESCRIBES R6 O TIAL PROP pOHHOUSC SEWER URE RMITT BACKFILLSEPTICTANKS ❑ SCb PIT($) ❑ CESSPOOLS A MATION ROBERT A WOOD CK M D CASH SUPERVISING MECHANICAL ENGINEER LJLOa 5 ,6 3-� AIJs12 1 0 0 1 0.00 IN —