HomeMy Public PortalAbout5442 TEMPLE CITY BLVD_Sewer__ I APPLICATION FOR PERMIT
TeAB+aD COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER SEWER-SEWAGE DISPOSAL
BUILDING AND SAFETY DIVISION BU w
A. 4 414121
WOALAIEMRBBDCSmPte1 dnS'.wq
LOCALITY
CROSS
SBST
FOR C O IN
DA
OEKfl11R10N L ZIAOWNER L/
MAIL �
BL ADDRESS
NO OF "LOGS
SIZE OF LOT NOW ON LOT CITY [ NO
UBE OF DISTRICT ND ROUP NAP PROCESSED MY
BUILDING" / "K PO
CONTRACTOR I p,I / 7
AD BeAbAz -�Y> CONNECTIONVDATA
CI TEL N STATION
6TAT[ MANHOLE REFERENCE UPIYR
RESIST A ON NO OUNTY R
NO ESCRIPT N OF WORK FEE TYPE O C ECT M H F M �r
HOUSE SEWER CONNECTING TO Y P P Qi
PUBLIC SEWER ® S%Go v
SEPTICTANK SEEPAGE PIT OR P N uPIT"AND/OR ORA INFIELD 0 stow CO IMP NO JOB NO
HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO
PRIVATE DIBFOSAL SYSTEM @ $3GG
CONNECT ADDITIONAL BLDG OR O AFFIDAVIT wM.O l.Va.Rt RECORD INSTR NO
WORK TO HOUSE SEWER Y s3 oo
OVERFLOW SEEPAGE PIT GRAINFIELD
EXTN CESSPOOL DRYW[LL MANHOLE• 55M
ALTER REPAIR OR ABANDON XOUB[ HWY OR ST WIDENING
SEWER OR O16P0"AL SYSTEM f100 STATE ENCROACXM[
PERMIT-
WASTE
ERMIT NO
WASTE A
���R�+� WASTE APPROVAL
OWNERS PERM $ 2 00 CHARGES
CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE
I HAVE AT THIS DAT[ A CONTRACT WITH THE HEREIN NAMED CON REIMBURSEMENT FEE
��
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING APPROVALS
TO THE PUBLIC SEWER DATE INSPECTOR S SIGNATURE
SIGNED THIS DAY OF ID_
OWNER OR NEW HOUSE SEWER
OWNERS AGENT CONNECTADDITIONAL
ADDRESS BUILDING OR WORKSEPTIC O
1 HERESY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION AND/OR
FIKIEEF PIT(B)
AND STATE THAT THE ABOVE IS CORRECT AND AOR[E TO COMPLY AND�OR pRAINFI[LD
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
PLUMBING AND SEWERS CESSPOOL ❑ ORYW[LL ❑
1D
CERTIFY THAT I AM PROPERLY REGISTERED AND/OR ALTER REPAIR SEWER OR
LICENSED AS REQUIRED BY LOS ANGLES COUNTY AND STATE OF SEWAGE DISPOSAL SYSTEM
CALIFORNIA OR THAT I AM THE _ __ _EOAL OWNER OF AND INTEND TO DISCON X[CT PLUG AND
RESIDE IN SOVE R[SI TIAL PROPERTY ABANDON HOUSE SEWER
SIGNATOR S
OF PERM BACKFILL SEPTIC TANKS ❑
BEEP PITS) ❑ CESSPOOLS
VALIDATI ROBERT A WOOD
cN r o^ cAeH SUPERVISING MECHANICAL ENGINEER
LAC01 9 8 4t2 OCT 29 1 0 D 5.00- V