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HomeMy Public PortalAbout5503 TEMPLE CITY BLVD_Sewer__ i CEBOB 0 IG-eB GA64 APPLICATION FOR PERMIT COUNTY OF LOS ANGELES SEWER—SEWAGE DISPOSAL DEPARTMENT OF COUNTY ENGINEER BUILDING AND SAFETY DIMION euILDINo aZ763 OHN A LA14B . County En {Sr Aooxwa WA JENSEN, Sup I of Building LOCALITY N[AR[°T FOR APPLICANT TO FILL °"°•• °' Dp{CRIPfION LOT NO OQ / OWNER M"L[LOCK TRACT MAIL / ADDR[a b NO OF [Loop SIZE OI LOT NOW ON LOT CI TEL NO USE OF iU1LDIN0[ DISTRICT NO GROUP MAP PROC BK PO D BY / CONTRACTOR �D g AODREw CO "OWQ /��^T� p CONNECTION DATA CITY TEL NO $:fD " O STATION ^' D[R in U RK013TRATION NO O COUNTY MA OL R[I R C[ R No DESCRIPTION OF WORK FE[ PEOFCO N[CTION L O FROM HOUSE SEWER CONNECTING TO CURB PL M L P L r PUBLIC SEWER i {B Go PC Q. aR"IC TA K BEEPAG[PIT OR O ,ITS AND/OR DRAINFI SLD $1000 CO IMP NO JOB NO U HOUSE SEWER CONNECTING TO TRUNK PERMIT NO ROAD PERMIT NO PRIVATE DISPOSAL SYSTEM iG 00 cc CONNECT ADDITIONAL{ DO OR4NAM&D AFFIDAVIT SMTTE �A�[S�rt RECORD INSTR x0 DAT[ 0 WORKTO HOUSE{EWLR 0 iEI� OVERFLOW SEEPAGE PIT GRAINFIELD t1WJ [ETH CESSPOOL ORYWELL MANHOLE Q {S SLA HOUSEHWY OR ST WIDENING H SEWERGR-0iMSBALSYSTCM O {3STATE ENCROACHMENT ? PERMIT NO OU RIAL PROVAL OWNERLS PERAII CHARGES T•R Z CONNECTION CHARGE PER AUTHORIZATION roto 1 HAVE AT THIS DAT[ A CONTRACT WITH THE REIMBURSEMENT IEE TRACTOR TO CONNECT THE ABOVE D[BCR APPROVALS TO THE PUBLIC 51JfWR_ DAT[ INSPECTOR BSIGNATURE SIGNED TH 18 J U DAY F W_ OWNERORZ4 [2 NESE HOUSE SEWER own[Re AGcxr coxxccr OR WOR AL BUILDING OR WORK AODRc[BSEPTIC TANK S[I. PlTlil IHEREBY ACKNOWLEDGE THAT 1 THIS APPLICATION AHD/OR GRAINFIELD AND STATE THAT THE ABOVE IB COAGREE TO COMPLYWITH ALL COUNTY ORDINANCES ALAWS REGULATINGPLUMBING AND SEWERSCESSPOOL ❑ DRYW[LL ❑IHEREBYCERTIFY THAT I AM PEGISTERED AND/OR ALTER REPAIR B[W[ROR LICENSED Ai REQUIRED BY LOS ATT AHD STATE OF SEWAGE DISPOSAL SYSTEM CALIFORNIA OR THAT 1 AM TH[ L[OOF AMD INT[XiTORESIDE IN THE ABOVE DESCRI• PROPERTY DISCONNECT PLUG ANO ABANDON HOUSE SEWER •IONATUR6BACKFILL B[PTIC TANKSOF PERMITTEEp[SP PIT 161 ❑ CESSPOOLS VALMATIOROBERT A WOOD CK M O CASH SUPERVISING MECHANICAL ENGINEER jL o 0 7 7 1APR 21 1 0 D 1 0.0 0 c